
Class "RQ . ^11 
Book ? . 



A PRACTICAL TREATISE ON 

NERVOUS DISEASES 



< 







A PRACTICAL TREATISE ON 

NERVOUS DISEASES 

FOR. THE MEDICAL STUDENT AND 
GENERAL PRACTITIONER 



BY 

F. SAVARY PEARCE, M.D. 

PROFESSOR OF NERVOCS AND MENTAL DISEASES IN THE INIEDICO-CHIRURGICAL COLLEGE 
OF PHILADELPHIA; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; 
NEUROLOGIST TO THE PHILADELPHIA AND HOWARD HOSPITALS; MEM- 
BER OF THE AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION, 
AND OF THE AMERICAN CLIMATOLOGICAL ASSOCIATION; 
CHAIRMAN OF SECTION ON NERVOUS AND MEN- 
TAL DISEASES OF THE AMERICAN 
MEDICAL ASSOCIATION 



COLOURED FRONTISPIECE 

NINETY-ONE ILLUSTRATIONS IN THE TEXT, MANY 

IN COLOURS 



NEW YORK AND LONDON 
D. APPLETON AND COMPANY 

1904 



LIBRARY of CONGRESS 
Tw« Copies Received 

FEB 24 1904 

<- Copyright Entry 
CLASS Be XXcNo, 
' "COPY^S 



Copyright, 1904, by 
D. APPLETON AND COMPANY 



PRINTED AT THE APPLETON PRESS 
NEW YORK, U. S. A. 



:i 



f 

f « 



DEDICATED TO 

S. WEIR MITCHELL, M.D,, LL.D. 

WHOSE LIFE HAS BEEN AN INSPIRATION FROM CHILDHOOD 

AND WHOSE FRIENDSHIP HAS BEEN OF 

VALUE SINCE EST MEDICINE 



PREFACE 



This text-book on Nervous Diseases has been written for the 
student and general practitioner. It has ever been the object to 
curtail details o-f the doubtful points in neurology and to make 
most in small compass of practical facts in the study of nervous 
disorders. We believe that this is the surest method of instilling 
knowledge of so intricate a subject. The chapter on anatomy 
and physiology has been blended^ so that its study will insure a 
pretty clear understanding of the anatomy and functions of the 
various parts of the nervous system. I have to thank my col- 
league, Prof. Isaac. Ott, for the physiological details given. I beg 
to acknowdedgCj among many other authorities, special reference 
to the works of Gowers, Mills, Dana, Barker, Osier, and Strlim- 
pell, to the latter three of which the author is also indebted for 
several cuts, for which credit is given in the text. I gratefully 
acknowledge the kindness for the use of illustrations from The 
Diagnostics of Internal Medicine, by Dr. Gr. R. Butler, and Acci- 
dent and Injury, by Dr. Pearce Bailey, respectively; also to Dr. 
M. K. Kassabian and Dr. G. E. Pfahler for the X-ray produc- 
tions and some of the photographs. 

It is the purpose of the author to follow this contribution by 
a similar treatise on Mental Diseases, so that the two works can 
be used in consonance by the medical student and busy practi- 
tioner. 

F. S. P. 

1409 Locust Street, Philadelphia, Pa. 



CONTENTS 



CHAPTER I 

PAGE 

Section I. — Anatomy : Classification of Nerves — Nerve centres . 1 

Nerve cells — varieties 2 

Nerve fibres — incisions of Lautermann 4 

Arrangement of nerve fibres 5 

Nerve centres in general 5 

Differentiation of tracts (three methods) 9 

Names of tracts 11 to 13 

Degenerations 13 

Tracts of descending degeneration 13 and 14 

" " ascending " 14 and 15 

Medulla oblongata 15 and 16 

Centres in medulla - . . .17 

Pons Varolii, etc. . . 17 and 18 

Cerebral peduncles .18 

Capsules of brain 91 

Cerebellum 19 and 20 

Cerebrum 20 and 21 

Optic thalami 21 and 21 

Corpora quadrigemini, etc 22 

Corpus striatum 22 

Membranes of brain and cord 22 

Section II. — Physiology : 

Functions of spinal cord . . . . . . . 22, 23 and 24 

Pfluger's laws 24 

Inhibition of reflexes . .24 

Brown-Sequard on reflex activity 25 

Reflexes of spinal cord 25 and 26 

Excitability of spinal cord 26 and 27 

Paths of spinal cord 27 and 28 

Nerve-fibres, functions of 28 

Irritability and stimuli of nerves .... 29, 30, 31 and 32 

Transmission of nerve impulses 32 

Relay stations of motor and sensory fibres 33 

Chemical and mechanical properties of nerve substance ... 33 

Physiology of the cerebellum 33 and 34 

ix 



X CONTENTS 

PAGB 

Section IL— Physiology : 

Functions of medulla . . . . . . . . 34, 35 and 36 

" " pons Varolii . . , 36 

" " cerebral peduncles . 36 

" " corpora quadrigemina 36 and 37 

" " corpora striata 37 and 38 

" " optic thalami 38 

The capsules, functions of, etc. . 38 and 39 

Functions of cerebral hemispheres 39, 40 and 41 

Sleep and waking 42 and 43 

Hypnotics 43 

Strength and liminal intensity of stimuli 43 

Weher-Feclinefs law 45 and 46 

After sensations . . . . . . . . . . .46 

Functions of the sympathetic system 46 

Other non-nervous tissues (blood-vessels, neuroglia) .... 47 
Section III. — Chemistry 47, 48 and 49 



CHAPTER II 

General pathology 50 

Sclerosis 50 

Degenerations 50 and 51 

Gliosis . 51 

Inflammations (varieties) 51, 52 and 53 



CHAPTER III 

General symptoms and methods of examination, nomenclature in nervous 

diseases 54 and 56 

Guide to note-taking 55 

The reflexes recapitulated 57, 58, 59, 60 and 61 

Trophic, vaso-motor and secretory phenomena 61 and 62 

Examination of the patient 62 

Gait and station (Romberg's sign) 62 

Grasp — dynamometer 63 

Pathologic gaits 63 and 64 

Physiognomy 64 

Temperaments 64 and 65 

Decubitus . . , 65 and 66 

Examination for sensation (aesthesiometer) 66 

" " motion 67 

Contraction and contracture 67 

Hemiplegia, monoplegia, paraplegia, diplegia 67 

Ataxic and other movements, static ataxia .68 

Table of tremors 68 



CO]S'TEjSTiS xi 

PAGE 

Conjugate deviation 69 

Pressure sense 69 

Muscular sense 69 

Weight sense . . . 69 and 70 

Sensations of motion 70 

Ocular disturbances 70 and 71 

Colour changes 71 

Pupillary symptoms (Argyll Robertson pupil) . . .71, 72 and 73 

Hearing, smell, taste 73 and 74 

Reflexes again studied 74, 75, 76 and 77 

Surface temperature 77 

" " in erythromelalgia - 77 

" thermometer (Mattson's) 77 



CHAPTER IV 

General therapeutics and prevention of nervous disease, and the acquire- 
ment of nervous health 77 

Hygiene 78, 79, 80 and 81 

Exercise . .81 and 82 

Hydrotherapeutics in nervous diseases 82 and 83 

Turkish bathing 82 and 83 

Details of Turkish bath 83 and 84 

Charcot douche, Scottish douche .85 

Drip sheet 86 

Massage — five sets of movements in . . . . . .86 and 87 

How to "rub" a patient , . . 88 and 89 

Salient points of massage . 89 and 90 

Contra-indications to massage 90 

Muscular movements , , . .90 

Exercises for hands and feet 90 and 91 

" " body and lower limbs 91 and 92 

Electricity 92 

Physics of 92 and 93 

Physiology of . . . 92 and 93 

Diagnosis and prognosis by . . 94 

Quantitative change 94 and 95 

Qualitative " 95 

Reaction of degeneration and examination for . . . 95 and 96 
Generation of electricity for practical therapy .... 97 
Some practical indications for galvanism . . . .97 and 98 
Regulations of galvanic current — axioms ... 99 and 100 
Stabile — labile — nodal point and sinusoidal current . . . 100 

Faradic electricity (induction current) 101 

Uses of Faradic electricity 102 and 103 

Franklin or static electricity ..,,... 105 



xii CONTENTS 

PAGE 

Hypnotism 105 and 106 

" Rest " treatment of Weir Mitchell .... 107 and 108 

Object of the " rest " treatment 108 

Care and treatment in convalescence from functional nervous 

disease 108 and 109 

Physical care, adjuncts and medication . . 110, 111 and 112 
Climatology of nervous disease ,..,... 113 

CHAPTER V 

Symptomatic disorders 114 

Vertigo 114 and 115 

Insomnia ......... 116 and 117 

Neuralgia 118 

Facial neuralgia 118 

Tic douloureux . . 118 and 119 

Intercostal neuralgia 119 and 120 

Sciatic neuralgia 120 

Anterior crural neuralgia 120 

Visceral neuralgia . . . . - 121 

Neuralgia of heart (angina) . 121 

Headache 121 

" causes of 122 

megrim . , 132 and 123 

Meniere's disease . . . 124 and 125 



CHAPTER VI 

Diseases of the cranial nerves • . . . . 126 

Olfactory nerve 126 

Optic nerve ' . . .126 and 127 

Oculomotor nerve 128 

Patheticus (or fourth nerve) 129 

Trifacial n 129 

Abducensn. . . ' . . . . . . . 129 and 130 

Facial n 130 and 131 

Auditory n 131 and 132 

Glosso-pharyngeal n 132 

Pneumogastric n. 133 

Spinal accessory n. 133 and 134 

Hypoglossal n 135 and 136 

CHAPTER VII 

Diseases of peripheral nerves . . . » » o ... . 136 

Origin of nerves ..-. ...» ... . 186 

Pathology of nerves 137 

Neuritis 137, 138 and 139 



CONTENTS xiii 

PAGE 

Multiple neuritis, special forms of 140 

Recurrent multiple neuritis 144 

Leprous neuritis . „ 144 and 145 

Sciatic neuritis 145, 146 and 147 

Tumours of nerves 149, 150 and 151 

CHAPTER VIII 

Diseases of other spinal nerves . 152 

Cervical plexus ', . . 153 

Long or posterior thoracic n 153 and 154 

Cervico-occipital neuralgia 155 

Infrascapular nerve 155 

Musculo-spiral nerve o 155, 156 and 157 

LTlnar nerve 157 and 158 

Median nerve 158 and 159 

Combined palsies of nerves of arm 160 and 161 

Brachial neuritis 161 and 162 

Nerves of the trunk 163 

" " " lower extremity »...,... 164 

Anterior crural n. , 164 and 165 

Obturator n . . . 165 

Superior gluteal n . . . . 165 

Great sciatic n. . » 165 and 166 

Internal popliteal n ' . . .166 

Metatarsalgia (Morton^s disease) 166 and 167 

Rhizomelique spondylitis 168 to 170 

CHAPTER IX 

Diseases of membranes of brain o 171 

Pachymeningitis externa . . , , . ... . .171 

Meningitis . ^ 171 and 172 

Acute cerebral pachymeningitis .... 172, 173 and 174 

Cerebral pachymeningitis haemorrhagica (or haeraatoma dura) 175 and 176 
Cerebral leptomeningitis . . . . . . . . . 177 

Hydrocephalus (acute and chronic) . . . . 177, 178 and 179 

Meningitis serosa 182 

CHAPTER X 

Diffuse and local disease of brain ......... 183 

Cerebral localization (epitomized) 183 

Occipital lobe 183 

Temporal lobe 184 and 185 

Prefrontal region ...» 186 

Centrum ovale 186 

Corpus callosum . 186 

" striatum ..,,,..... 186 



XIV 



CONTENTS 



PAGE 

Optic thalamus 186 

Internal capsule , 187 

Crus cerebri 188 

Pons or bulb 188 

Cerebellum 188 

Medulla oblongata . 188 

Aphasia (varieties) 189, 190 to 194 



CHAPTER XI 



Other diseases of brain and membranes 
General symptomatology 
Malformations of brain and membranes 

Meningocele 

Apoplexy (cerebral htemorrhage) 

" diagnosis .... 
" prognosis .... 
" treatment and nursing 

Encephalitis 

Brain tumour (cerebral neoplasm) 
" symptoms and localization 
" pathology, diagnosis, prognosis and treatment 



198, 



. 195 
. 195 

196 and 197 

197 and 198 
199, 200 and 204 

. 205 

. 205 

205 and 206 

207 and 208 

209 and 210 

210 and 211 

211 and 212 



CHAPTER XII 

Inflammations of membranes of cord and unclassified diseases 
Inflammations of spinal dura (pachymeningitis) 
" " " pia (leptomeningitis) . 

Caisson disease (divers' disease) 

Landry's disease (acute ascending paralysis) 



213, 



. 213 

214 and 215 

215 and 216 
217 and 218 
219 and 220 



CHAPTER XIII 

Diseases of the spinal cord . ■ 221 

General considerations 221 

Special diseases 222 

Malformations: Heteropia, meningocele, amyelia, double cord, split- 
ting of cord, agenesis, micromyelia . . 223, 224, 225 and 226 

System diseases (sensory and motor neurons) 226 

Locomotor ataxia (tabes) ; (symptoms, diagnosis, prognosis and 

treatment) 226, 227 to 233 

^rimary lateral sclerosis 234 to 236 

pastic spinal paralysis 236 to 238 

[ereditary spastic spinal paralysis 238 

.•iedreich's disease (hereditary ataxia) .... 238 and 239 

erebellar ataxia 240 

-•-tional disorders of spinal cord . 240 

a equina — diseases of ...,., , 241 and 242 



CONTENTS XV 

CHAPTER XIV 

PAGE 

Diffuse and local disease of spinal curd 243 

Spinal anaemia; spinal haBmorrhage (spinal apoplexy) . . . 244 

(1) Haematorrhachis ; (2) haematomyelia 244 to 247 

Syringomyelia 247, 248 and 249 

Muscular dystrophies (varieties) . . , . . 250 to 252 

(1) Pseudohypertrophic paralysis .... 250, 251 and 252 

(2) Idiopathic muscular atrophy . . . . . . . 252 

(a) (Facio-scapulo-humeral) 252 

(b) (Juvenile form of Erb) 254 

(3) Neuritic type 254 and 255 

Anterior poliomyelitis acuta (infantile palsy) . . 255, 256 and 257 
Glosso-labio-pharyngeal palsy (bulbar palsy) ; (1) acute ; (2) chronic ; 

(3) asthenic; (4) pseudo 257 and 258 

Combined scleroses 260 

(1) Hereditary ataxia (see p. 238) . . . . . . .260 

(2) Type of Putnam-Lichthein-Dana . . \ . . 260 to 262 
Myelitis : Causes, types, symptoms, prognosis, pathology and treat- 
ment 262, 263, 264 to 266 

CHAPTER XV 

Diffuse diseases of brain and cord 267 

Multiple or insular sclerosis : Symptoms, diagnosis, prognosis and 

treatment 267, 268 and 269 

Paralysis agitans (Parkinson's disease) . . 269, 270, 271 and 272 

Nervous syphilis 272 

General considerations . . . 272 

Pathology 273 and 274 

Diagnosis 275 

Prognosis 275 

Treatment 275 and 276 

CHAPTER XVI 

General and functional nervous diseases 277 

Classification 277 

Chorea minor (St. Vitus's dance) : Types, symptoms, diagnosis, 

prognosis and treatment 278 to 282 

Habit chorea (habit spasm) 283 and 284 

Hereditary chorea (Himtijigdon's disease) . . 284, 285 and 286 

Convuhiye tic {Giles de la Totireite's disease) . ., . 286 and 287 

Saltatory spasm (jumpers' disease) 287 and 288 

Myotonia congenita (Thorasen's disease) .... 288 and 289 

Epilepsy 289 and 290 

Definition, aetiology, symptomatology, pathology, diagnosis, 

prognosis and treatment 289 to 295 

Neurasthenia (nervous exhaustion) ,,..,.. 295 



xvi COXTEXTS 

Page 
Symptoms, letiology, pathology, diagnosis, prognosis and treat- 
ment 295 to 303 

Hysteria 303 

Symptoms, aetiology, pathology, diagnosis, pro^osis and treat- 
ment . . . 302 to 308 

Tranmatic hysteria (railway spine) 308 

Symptoms, aetiology, diagnosis, prognosis and treatment . 309 to 312 

Saltatory spasm 312 

" Salaam convulsions 312 

Writer's cramp (artisan's palsy) : Symptoms, types, prognosis, treat- 
ment 313 and 314 



CHAPTER XA1I 

Vasomotor and trophic disorders 316 

Exophthalmic goitre (Graves' dis€fase) : Causes, symptoms, prog- 
nosis and tceatment 316 to 319 

Glass-blowers' disease . . . . 319 

Sndden changes ia the hair 820 and 321 

Hyperostosis cranii (cephalomegaly) 323 and 324 

Adiposis dolorosa 324 and 325 

Facial hemiatrophy 326 

" hemihypertrophy 326 

Dermatitis gangrenosa nervosa 327 and 328 

Myxoedema and cretinism , . .... S'2S and 329 

Scleroderma 3-^9 a id 330 

Ainhum 330 

Acromegaly 331 to 333 

Hypertrophic pulmonary osteo-arthropathy . . . 333 and 334 
Arthritis deformans (rheumatoid arthritis) .... 334 to 340 

Heat exhaustion 340 and 341 

Sunstroke (insolation 341 and 342 

Myasthenia gravis 342 and 343 

Family periodic paralysis , . 343 and 344 

CHAPTER XVIII 

General toxfemic diseases of the nervous system 345 

Hydrophobia (rabies) ....... 345 and 346 

Tetanus (lockjaw) 347, 348 and 350 

Tetany (tetamlla') 350, 351 and 353 

CHAPTER XLS 

Drug intoxications 354 

Alcoholism (alcoholic irsanity) 354. 355 and 356 

Tobacco poisoning ........ 356 and 857 

Tea and coffee poisoning 357 



CONTENTS xvii 

PAGE 

Lead, mercury, and arsenic poisoning .... 357 and 358 

Opium poisoning , 358 and 359 

Cocaine habit 359 and 360 

Coal-tar-products intoxication ...... 360 anu 361 

CHAPTER XX 

General paresis (paresis) : Types : symptoms, aetiology, pathology, diag- 
nosis, prognosis and treatment . . . . . . 362 to 366 

Syphilitic pseudo-paresis 366 

Alcoholic pseudo-paresis 866 

Treatment of all forms 368 



APPENDIX 

Disorders of sleep 369 

(a) Wakeful disorders 370 and 371 

(b) Somnolent '' 372 and 373 

Additional figures 373 to 384 

Tables ^ 385 and 386 

Formulary , . 387 to 390 



LIST OF ILLUSTRATIONS 



FIG. PAGE 

Erythromelalgia of right foot Frontispiece 

1. The neurone (diagrammatic) 3 

2. Functions of the fibres of the anterior and posterior roots, etc. . . 6 

3. The parts and columns of the spinal cord, and some of the diseases 

which affect them 6 

4. Tracts of the spinal cord and their varied nomenclature ... 8 

5. Functions of the various tracts of the spinal cord 10 

6. The relation of the segments of the spinal cord, etc., to the spinous 

processes of the vertebras 13 

7. Sensory pathways 44 

8. Motor pathways 45 

9. The relation of the spinal cord to the dorsal surface of the trunk, etc. 47 

10. Position of hand in local tonic hysterical spasm 56 

11. Krauss's plessimeter 57 

12. The Jendrassik method of obtaining the knee-jerk .... 58 

13. Taylor knee-jerk hammer 59 

14. Showing the method of obtaining the triceps and supinator jerk. . 60 

15. Weir Mitchell's apparatus for clinical observations of station . . 62 

16. Dynamometer 62 

17. Hand-dynamometer 63 

18. Carroll's ^sthesiometer . . 66 

19. Diagram of visual paths 73 

20. Mechanism of deep reflexes ; also the two main types (spastic and flac- 

cid) of paralysis . . . 75 

21. Complete galvanic dry-cell battery 100 

22. Combination dry-cell galvanic and faradic battery .... 101 

23. Complete electric cabinet 102 

24. Static machine and complete series of electrodes 104 

25. Congenital nystagmus 128 

26. Facial palsy, left side 130 

27. Attitude in spasmodic torticollis . . 134 

28. Supranuclear palsy of the right hypoglossal nerve .... 135 

29. Bedridden case of multiple neuritis 141 

30. Wrist drop from musculo-spiral alcoholic pressure palsy . . . 157 

31. Distribution of the sensory nerves of the skin of the arm, anterior 

aspect 159 

32. Distribution of the sensory nerves of the skin of the arm, posterior 

aspect . c 159 

xix 



XX LIST OF ILLUSTEATIONS 

FIG. PAGE 

33. Distribution of the sensory nerves of the skin of the leg, posterior 

• aspect 159 

34. Distribution of the sensory nerves of the skin of the trunk and leg, 

anterior aspect • . 162 

35. Distribution of the sensory nerves of the skin of the trunk, posterior 

aspect 164 

36. Distribution of the sensory nerves of the skin of the foot . . . 167 

37. Rhizomelique spondylitis 169 

38. Haemorrhagic pachymeningitis interna (alcoholic) .... 176 

39. Brain ; case of hydrocephalus in a child of five years .... 180 

40. Spastic diplegia from chronic hydrocephalus (adult male) . . . 181 

41. Schematic representation of the cerebral cortex and its centres . . 184 

42. View of the right cerebral hemisphere from the median side . . 185 

43. Diagram of motor and sensory representation in the internal capsule. 187 

44. Zones and centres. External aspect. Cerebrum 190 

4*5. Zones and centres. Mesal aspect. Cerebrum 192 

46. Flechsig's association areas, lateral aspect 193 

47. " " " mesal aspect 194 

48. Lack of development. Left half of cerebrum 197 

49. Arteries at the base of the brain 199 

50. The portions of the cerebral hemisphere supplied by the anterior, 

middle and posterior cerebral arteries 200 

51. Area of thrombosis and haemorrhage motor area cerebrum. X-ray 

photograph 201 

52. Hyperpyrexia in cerebral haBmorrhage ; male, aged sixty-one years . 203 

53. Chronic cervical tubercular external pachymeningitis .... 214 

54. Atrophy of interossei, thenar and hypothenar muscles of both hands . 216 

55. Agenesis and micromyelia of spinal cord in a male aged forty years . 225 

56. Standing posture, static ataxia in tabes dorsalis 228 

57. Charcot joints in tabes 230 

58. Tumour (psammoma) springing from dura, lower dorsal cord . . 241 

59. Atrophy of intrinsic muscles of the hand with thermo-anaesthesia . 248 

60. Pseudohypertrophic paralysis showing atrophy of shoulders, girdle 

and thighs 251 

61. Progressive muscular atrophy of spinal origin . . . . . 253 

62. Combined sclerosis of the type Putnam-Lichthein-Dana, followed by 

left hemiparesis 261 

63. Expression " pill-rolling" hands and attitude in paralysis agitans . 269 

64. Communications of the nervous system to the genital organs . . 296 

65. Hysterical paralysis; braces and wheel-crutch applied to assist in 

walking 306 

66. Exophthalmic goitre. Prominent eyes and thyreoid gland . . 316 

67. Trophoneurosis of the hair, showing change from dark to white . . 320 

68. Universal alopecia of nervous origin 321 

69. Hyperostosis cranii 322 

70. Skull-cap from same case of hyperostosis cranii 323 

71. Adiposis dolorosa in a colored woman 325 

72. Dermatitis gangrenosa nervosa, showing scars on left hand . , . 327 



LIST OF ILLUSTRATIONS xxi 

Fia. PAGE 

73. Sporadic cretinism 328 

74. Acromegaly in a woman, showing enlarged supra-orbital ridges, infe- 

rior maxilla and liands 332 

75. Agglutination of patella to tibia and subluxation of knee in rheuma- 

toid arthritis ; X-ray photograph 335 

76. Erosion joints of hands. Kheumatoid arthi'itis. X-ray photograph . 336 

77. Rheumatoid arthritis with contractures 338 

78. Rheumatoid arthritis, after operation and braces are applied . . 339 

79. Paretic dementia, ordinary type, second stage 363 

80. Spastic and athetoid movements in face, tongue, and pharyngeal muscles 373 

81. Attitude in a case of general athetosis in cerebral palsy of childhood 374 

82. Secondary contractions of face, arm, hand, foot, and leg in case of 

chronic left hemiplegia 375 

83. Tumour (endothelioma), inner surface cerebral dura .... 376 

84. Horizontal linear light shadow (radiograph), showing result of specific 

meningitis and erosion of inner plate of parieto-frontal bones . 377 

85. Showing motor points (head and neck) - . 378 

86. Showing motor points (shoulder and arm) anterior aspect . . . 379 

87. " " " " " ^' posterior "... 380 

88. " '• " (leg) 381 

89. Showing the effects of various lesions of the motor path in the brain 

and spinal cord 382 

90. Diagram of skin areas corresponding to the different spinal segments 

(anterior aspect) 383 

91. Diagram of skin areas corresponding to the different spinal segments 

(posterior aspect) 384 



A PRACTICAL TREATISE ON NERVOUS 
DISEASES 



CHAPTEE I 

GENERAL ANATOMY, PHYSIOLOGY, AND CHEMISTRY OF 
THE NERVOUS SYSTEM 

Section I. — Anatomy 

The structure of the nervous system may be distinctly divided 
into five parts, as follows : 

1. Xon-medullated nerve-fibres. 

2. Medullated nerve-fibres. 

3. Kenroglia. 

4. Supporting connective-tissue framework, besides the neu- 
roglia. 

5. Nerve-cells. 

Classification of Nerves. — Nerve-fibres may be classified into 
three main groups, according to the direction in which they con- 
vey normally nervous impulses. These three divisions are: 

1. Efferent nerve-fibres. 

2. A.fferent nerve-fibres. 

3. Intercentral nerve-fibres. 

Efferent or centrifugal nerves are those which conduct nerv- 
ous impulses from the central nervous system (brain and spinal 
cord) to other parts of the body. 

Afferent or centripetal nerves are those which conduct nervous 
impulses in the opposite direction — namely, from all parts of 
the body to the central nervous system. 

Intercentral nerves are those nerves which connect nerve-cen- 
tres together; they connect different parts of the brain and of 
the cord to one another. 

Nerve-Centres. — Nerve-centres are composed of white and gray 
matter. In the brain the gray matter is on the outside, and in 
1 I 



2 TREATISE ON NERVOUS DISEASES 

the spinal cord it is on the inside. The white matter is made up 
of nerve-fibres, and the gray matter of cells and an interposing 
cement substance called neuroglia. It is expedient to here explain 
what is meant by the neuroglia. This is the cementing tissue of 
the nervous system, of ectodermic origin — differing from connect- 
ive tissue, which is solely derived from the mesoderm — and in the 
spinal cord it arises in part from the pia mater and passes into 
the white matter, carrying with it blood-vessels, and forming ssepta 
which separate the nerve-fibres into bundles. Neuroglia proper 
is made up of a delicate reticulum, holding in its meshes the 
small glia cells. 

Nerve-Cells. — Nerve-cells differ greatly in size and shape. 
The nucleus is generally large and spherical, containing a dis- 
tinct nucleolus. They may be roughly divided into three groups, 
according to the number of protoplastic processes they possess, 
into unipolar, bipolar, and multipolar cells. 

Unipolar cells are found in the spinal ganglia. They are 
spherical in shape, are inclosed in a nucleated sheath, and the 
single process after a short course joins one of the nerve-fibres 
traversing the ganglion by a T-shaped junction. 

Bipolar cells are cells with two branches or processes. The 
embryonic condition of the cells of a spinal ganglion is one ex- 
ample of these. 

Multipolar Cells. — Here the cell becomes angular or stellate. 
It was formerly thought, in some instances, as in the cells of the 
sympathetic ganglia, that all the processes become nerve-fibres, 
but this is not so, for here, as well as in the large cells of the gray 
matter of the spinal cord, only one process becomes the axis cylin- 
der of a nerve-fibre, the others dividing and subdividing in a 
ramified manner until they end in an arborescence of fine twigs. 

The nerve-cell is the fundamental characteristic unit of the 
gray matter, and is known as a neuron (Waldeyer, 1891). Some 
of these cells are coloured or pigmented, such as in the locus niger, 
where they are black; nucleus ruber, where they are red, as its 
name would imply, etc. Every nerve-cell has an axis-cylinder proc- 
ess, which has been variously called the axis cylinder, neurit, ax- 
one, or neuraxon. The protoplasmic prolongations of the nerve- 
cells are called dendrons. According to the number of these proc- 
esses, the nerve-cells are termed, as before stated, unipolar, bipolar, 
and multipolar. 



N 

E 
U 
R 


N 
E 



Dendrites 



Cell body 



AXONE 
(axis cylinder) 



End brush 
(or terminal 
arborization) 



N 
E 
U 
R 

N 




B 



I Carry impulses to the cell 

( Degenerate if separated from it 



Is the container and generator of 

nerve force 
Is trophic for dendrites and axones 



Carries impiilses from the cell body 
Degenerates if separated from it 



A * Upper or cerebral motor 

NEURONE 

Exercises an inhibitory con- 
trol OVER B 



{Intermingles but does not unite with 
dendrites of neurone to which it 
carries impulses 



B - Lower or peripheral mo- 
tor neurone 

Exercises trophic influence 

OVER and maintains TONUS 
OF MUSCLES 




End organ 
In muscular fibre 

Fig. 1. — The neurone (diagrammatic). (From Butler's Diagnostics of Internal Medi- 
cine, 1902.) 



4 TREATISE ON NERVOUS DISEASES 

The nerve-cells vary from ^-qVit ^^ ri^ir ^^ ^^ ^^^^ i^ diameter. 
The largest nerve-cells are found in the anterior horns of the 
spinal cord and in the vicinity of the fissure of Rolando. 

Nerve-Fibres. — The nervous S3^stem is composed of two parts — 
the central nervous system and the periylieral nervous system. 
The central nervous system consists of the brain and the spinal 
cord; the peripheral nervous system consists of the nerves which 
conduct the nervous impulses to and from the central nervous 
system, and thus bring the nerve-centres in relation with other 
parts of the body. 

Nerve-fibres are of two histological kinds, viz., medullated and 
non-meduUated. Medullated nerve-fibres are found in the white 
matter of the nerve-centres and in the nerves originating from 
the brain and spinal cord. Non-medullated nerve-fibres occur in 
the sympathetic system. 

The medullated or white fibres are characterized by the sheath 
of white colour, fatty in nature, and stained black with osmic 
acid; it is called the medullary sheath or white substance of 
Schwann; this ensheaths the essential part of the fibre, which is 
a process from a nerve-cell, and is called the axis cylinder. Ac- 
cording to Piersol, the axis cylinder is covered by a thin, trans- 
parent, elastic sheath, called the axilemma. The substance of 
Schwann is ensheathed by a thin, homogeneous membrane of an 
elastic nature, called the neurilemma. 

The axis cylinder is made up of a number of small fibrils, which 
are held together by a cement substance called the neuroplasm. 

Along the course of a medullated nerve-fibre there are numer- 
ous constrictions called the annular constrictions or nodes of Ran- 
vier. At these constrictions the neurilemma lies in direct contact 
with the axis cylinder of said nerve. According to some author- 
ities, the axilemma lies interposed. The stretch of nerve between 
two nodes is called an internode, and in the middle of each node 
is a nucleus which belongs to the primitive sheath. The nucleus 
is not necessarily always in the middle, for in some cases it is 
found to be variously distributed. 

Incisures of Lantermann. — In each interannual segment in a 
nerve that is stretched there will be noticed a number of oblique 
lines running across the white substance of Schwann. This indi- 
cates that the segments of Schmidt are built up of a series of 
conical sections, each of which is bevelled at its ends, while the 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 5 

slight interval between them appears as an incisure of Lanter- 
mann. 

The fibres of the nerve-centres differ from the preceding in 
that they have no neurilemma and no annular constrictions. When 
a nerve enters the spinal cord or brain it loses its neurilemma. 

The non-medullated fibres or fibres of Eemak have no medul- 
lary sheath^ and are therefore devoid of the double contour of the 
medullated fibres, and are unaftected in appearance by osmic acid. 
They consist of an axis cylinder covered by a nucleated fibrillated 
sheath. These nerves branch very frequently. They are princi- 
pally found in the sympathetic system, a few being found in the 
spinal nerves mixed with the medullated fibres. 

Arrangement of Nerve-Fibres. — The arrangement of nerve- 
fibres is best seen in transverse section. 

The nerve is composed of a number of bundles of funiculi of 
nerve-fibres bound together by connective tissue. The sheath of 
the whole nerve is called the epineurium ; that of the funiculi the 
perineurium', that which passes between the fibres in a funiculus 
the endoneurium. 

The size of a nerve-fibre is from g-oVo" ^o ygVo ^^ ^^ i^^h in 
diameter. 

Nerve-Centres in General. — The nerve-centres in general are 
the spinal cord, medulla oblongata, pons varolii, cerebellum, and 
cerebrum. 

Spinal Cord. — The spinal cord is enclosed in the bony canal 
formed by the spinal vertebrae; it extends from the margin of the 
foramen magnum to the lower border of the first lumbar vertebra, 
terminating in a slender filament of gray substance, the filum 
terminale, which lies in the midst of the roots of many nerves 
forming the cauda equina. It does not fill the canal altogether, 
but is suspended in the cerebro-spinal fluid. It has two enlarge- 
ments, one in the cervical, the other in the lumbar region. These 
are the situations whence the large nerves for the supply of the 
limbs issue. The spinal cord is from 15 to 18 inches in length 
and weighs about one ounce. 

It is composed of white and gray matter; the white matter 
is situated externally, and constitutes its chief portion; the gray 
matter is in the interior, being so arranged that in a transverse 
section of the cord it appears like two crescentic masses which 
are connected together by a narrower portion which is known as 



PAIN AND TEM 
PERATURE SENSE 



"^^yj^lJ^MUSGLE SENsil 



REFLEX AND 
VISCERAL, 




V \11 


■Vv.'V-;.-' 


J \ '^ 


>^v;c/; 


/\ 


^ \ MOT 


DR R 


DIRECT 


^*-^ 


PYRAMID. 







Fig. 2. — Showing the functions of the fibres of the anterior and posterior roots, and 
their relations to the horns and columns of the spinal cord. (Redrawn and modi- 
fied from Dana.) 




Pig. 3. — Showing the parts and columns of the spinal cord and some of the diseases 
which affect them. (From Butler.) 



ANATOMY, PHYSIOLOGY, AND CHEMISTKY 7 

the posierior commissure. In the centre of this narrow portion 
is located the central canal. Directly in front of the posterior 
commissure is located the anterior commissure, which is composed 
of white matter. 

The spinal cord consists of two lateral halves, separated an- 
teriorly by the anterior median fissure, which extends from the 
front surface of the spinal cord to the anterior or white commis- 
sure. Posteriorly it is separated indistinctly by the posterior me- 
dian fissure, which extends from the posterior surface of the spinal 
cord to the posterior or gray commissure. The posterior fissure 
is deeper than the anterior, but it is not as wide nor is it so dis- 
tinct. The posterior fissure extends from the calamus scriptorius 
in the fourth ventricle above to the termination of the cord below. 

On the lateral surface of the cord are noticed two longitudinal 
furrows, which divide each half of the cord into three columns, 
viz., anterior, lateral, and posterior. From the furrow between 
the anterior and lateral columns spring the anterior {motor) 
nerves; from the furrow between the lateral and posterior col- 
umns spring the posterior (sensory) nerves. 

The cord is composed of a cortical white substance and a cen- 
tral gray matter. The white matter is made up of medullated 
nerve-fibres of different sizes, arranged longitudinall}^, and of a 
supporting material of two kinds, viz. : (a) Ordinary fibrous con- 
nective-tissue ssepta with elastic fibres, which is connected with 
sgepta from the pia mater, passing into the cord to carry blood- 
vessels; (h) neuroglia; the processes of the neuroglia cells are 
arranged so as to support the nerve-fibres which are without the 
usual external nerve-sheaths. The gray matter of the cord con- 
sists of nerve-fibres, most of which are very fine and delicate, of 
nerve-cells with branching processes, and of an extremely delicate 
network of the primitive fibrillge of axis cylinders. This fine net- 
work is called Gerlach's network, and is mingled with the meshes 
of neuroglia. The neuroglia of the gray matter resembles that in 
white matter, but instead of everywhere forming a close network 
to support the nerve-fibres, here and there it is in the form of a 
more open sponge-work to support the nerve-cells. It is espe- 
cially well developed around the central canal, being called here 
the suhstantia gelatinosa centralis. At the ..tip of the posterior 
horn it is also well developed, and is called suhstantia gelatinosa 
lateralis of Rolando. The latter is well developed in the cervical 
1* 




Fig. 4.— Showing the tracts of the spinal cord and their varied nomenclature. 
Red = motor (or efferent). Blue = sensory (or aff"erent). (Butler.) 



ANATOMY, PHYSIOLOGY, AND CIIEMISTEY 9 

region. The gray substance is thicker in the lumbar and cervical 
regions than anywhere else. The gray substance of the horns or 
cornua causes the anterior horns to be thicker than the posterior. 
The anterior horns do not quite reach the free surface of the 
cord, while the posterior horns do. 

The groups of cells in the gray matter are either scat- 
tered singly or arranged in groups, of which the following 
are to be distinguished on either side. The nerve-cells in the 
anterior horn of gray matter are principally large, multipolar, 
ganglion cells. They are arranged as a mesial group, near the 
inner aspect of the horn, and an anterior and a lateral group. 
The column of Clarice is a column of nerve-cells situated at 
the junction of the posterior horn with the gray commissure. 
These latter cells are seen only in the thoracic portion of the 
cord. The smallest nerve-cells are found in the posterior horns 
of the cord. 

The fibres of the spinal cord are of two kinds — the extrinsic 
and intrinsic. The extrinsic fibres begin in the cerebrum of the 
brain, perhaps in the cerebellum, and run down the spinal cord to 
cells therein. The intrinsic fibres connect different parts of the 
spinal cord with each other. 

Differentiation of Tracts. — The white matter can be systemat- 
ically divided into different tracts by the following methods of 
observation : 

1. Emhryological Method. — It has been found by examining 
the spinal cord at different stages of its development that certain 
groups of fibres put on their myelin sheath at earlier periods than 
others, and that the different groups of fibres can therefore be 
traced in various directions. This is sometimes called the Fleclisig 
method. 

2. Wallerian or Degeneration Method. — This method depends 
upon the fact that if a nerve-fibre is separated from its nerve- 
cells it wastes or degenerates. It consists in tracing the course 
of tracts of degenerated fibres which result from an injury to any 
part of the central nervous system. When fibres degenerate below 
a lesion, the tract is said to be descending degeneration, and when 
the fibres degenerate in an opposite direction, the tract is one of 
ascending degeneration. 

3. Another method is by removing an organ of special sense, 
and then tracking the degenerated fibres. 




''"'■ forefeetrf "" *™°"°"^ of *''« "■■■<"••' "--'^ of the spinal cord. Red = ,„ot„. 
(.or efferent). Blue - sensory (or afferent). Compare with Pig. 4. (Butler.) 



AXATOMY, PHYSIOLOGY, AXD CHEMISTRY 11 

Tracts discovered by the above Methods of Determination. — 

The spinal cord may be considered as a series of segments super- 
imposed one upon the other, corresponding to the pairs of spinal 
nerves. Each of these sections is a complete centre, is sup- 
plied with nerve-cells and with motor and sensory nerves. The 
nerve-cells are grouped into motor and sensory iields, united 
by the intraspinal fibres. These commissures or fibres are very 
short. 

1. Anterior Column. — This is composed of fibres known as 
the commissural fibres, and the innermost contribute to the for- 
mation of the white commissure of the cord. There are two tracts 
located in the anterior column, viz. : on either side of the anterior 
median fissure a portion of the column is taken up by the direct 
pyramidal tract (fasciculus of Turk), which can be traced to 
be continuous with the non-decussating fibres of the pyramid of 
the medulla. The rest of the anterior column is composed of 
fibres of the anterior lateral ground 'bundle. The anterior column 
would be. bounded in the following manner : internally by the an- 
terior median fissure, externally by the anterior horn and nerves 
springing from same, and anteriorly by the free surface of the 
cord. It may be stated that it is more or less triangular in shape. 
Some observers claim that the anterior lateral ground handle is 
wholly situated in the lateral column. 

2. Lateral Column. — This column is composed of fibres which 
are larger on the surface of the cord and smaller in the deeper 
portions. There is no decussation in the spinal cord of these 
fibres. It is made up of the following tracts, viz. '.crossed pyram- 
idal, direct cerehellar, anterior lateral ascending, sometimes called 
tract of Gowers, anterior lateral descending, sometimes called 
tract of Lowenthal; Lissaiier, mixed lateral tract, and the an- 
tero-lateral ground bundle. The direct cerebellar, or tract of 
Flechsig, is situated at the posterior superficial part of the lateral 
column. This extends downward as far as the second lumbar 
nerve, and upward as far as the restiform body, with which fibres 
it passes into the cerebellum. Gowers's tract occupies the anterior 
superficial surface of the lateral column. It commences in the 
lumbar swelling and terminates in the cerebellum, passing through 
the superior peduncles. The lateral column would be bounded in 
the following manner : internally by the anterior and posterior 
horns and nerves leading from the anterior horn ; externally the 



ROOTS 



SPINOUS PROCESS 



EXITS 



C I ARISES ABOVE ATLAS 

II ARISES OPPOSITE ATLAS 

III ARISES AT ATLAS 

IV ARISES BETWEEN 2nd & 3rd SPINE 
V „ OPPOSITE 3rd SPINE 



VI 

VII 

VIII 
D I 
II 

III 

IV 

V 

VI 

VII 

VIII 

IX 

X 
XI 
XII 

1. 1 
II 

III 

IV 
V 



S I 

II 
III 

IV 



4{h .. . 

Bih - . 

6th .> . 

6th 

7th ,. . 

1st DORSAL SPINe. 

2nd 

3rd 

4th 

5th 

6th 

7th 

8th 

9th 
10th 
11th 



'- /// 



BJack Dots ^Points of Origin. 
CircJes- Points of Exit. 
C = Cervical. D = Dorsal. 

1^ = Lumbar. S^ Sacral. 



BETWEEN ATLAS & OCCIPUT 
ABOVE ATLAS 

ABOVE 3rd CERVICAL SPINE 
4th n 

5th /> ,, 

6th 

7th ,i 

1st DORSAL SPINE 
BETWEEN 1st & 2nd DORSAL SPINE 
2nd,, 3rd „ 

3rd,, 4th „ „ 

4th ,, 5th 

5th ,, 6th .1 „ 

6th „ 7th „ „ 

,; 7th ,, 8th a ,i 

„ 8th „ 9th n u 

9th „ 10th n ,1 

10th „ 11th „ n 

11th & 12th „ I, 

BETWEEN 11th 
DORSAL & 1st LUMBAR ,, 

1st & 2nd „ 

2nd,. 3rd „ 

3rd,i 4th „ 



4th ,, 5th „ 

BETWEEN 5th 
LUMBAR & 1st SACRAL 



1st & 2nd 
2nd,, 3rd 
3rd,, 4th 
4th „ 5tH 



Fig. 6. — Diagram showing the relation of the segments of the spinal cord, and of the roots 
and exits of the spinal nerves, to the spinous processes of the vertebrae. 
13 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 13 

lateral column is comprised between the lines of implantation 
of the anterior and posterior roots. 

3. Posterior Column. — This column is composed of fine fibres, 
and is remarkable for its abundance of neuroglia. It is made up 
of the following tracts — GolVs and Burdacli's. The internal col- 
umn, near the posterior fissure, is apparent at the upper part of 
the cord in the form of a slight enlargement. It is formed of 
long commissural fibres. The fibres rise as low down as- the cauda 
equina, and run up to the nucleus of Goll in the medulla oblongata. 
The tract of Burdach is developed before the tract of Goll. Bur- 
daclrs tract terminates in the nucleus of Burdach. The poste- 
rior column would be bounded in the following manner : inter- 
nally by the posterior median fissure, externally by the posterior 
horn, and posteriorly by the free margin or surface of tiie 
spinal cord. 

The gray columns of cells of the cord are Clarl-e's, and inier- 
medio-lateral tracts. 

Degenerations. — We now pass from this to consider the tracts 
of degeneration that occur when the spinal cord is cut right across 
in the thoracic region. Some tracts will be found degenerated in 
the piece of cord below the lesion; these consist of nerve-fibres 
that are connected with the nerve-cells in th& brain ; they are called 
the pyramidal tracts. Other tracts are found degenerated in the 
piece of cord above the lesion ; these consist of fibres that are con- 
nected with the nerve-cells of the spinal ganglia, or with the cells 
of the spinal cord itself below the lesion, and are passing upward. 

The tracts which degenerate downward are the motor tracts; 
the tracts that degenerate upward are the sensory tracts. 

Tracts of Descending Degeneration. — 1. Crossed Pyramidal 
Tract. — This tract is situated in the lateral column on the outer 
side of the posterior cornu of gray matter. At the lower part 
of the spinal cord it extends to the margin, but higher up it 
becomes displaced from this position by the interpolation of an- 
other tract of fibres, viz., the direct cerebellar tract. The crossed 
pyramidal tract is large, and may touch the gray matter at the 
tip of the posterior cornu, but is separated from it elsewhere. Its 
shape on cross-section is somewhat like a lens, but varies in dif- 
ferent regions of the cord, and diminishes in size from the cervical 
region downward, its fibres passing off as they descend, to arborize 
around the nerve-cells and their branchings in the gray matter 



14 TREATISE OX XERVOUS DISEASES 

of the cord. The fibres of which this tract is composed are mod- 
erately large, but are mixed with some that are smaller. 

2. Direct Pyramidal Tract. — This tract is situated in the an- 
terior column by the side of the anterior fissure. It is small in 
some animals, but is quite conspicuous in the human spinal ^cord. 
It can be traced upward to the brain, and downward as far as 
the mid or lower thoracic region, where it ends. 

The two pyramidal tracts come down from the brain ; in the 
medulla oblongata, the greater number of the pyramidal fibres 
cross over to the other side of the cord which they descend, hence 
the term " crossed pyramidal "' tract ; a smaller collection of the 
pyramidal fibres goes straight on on the same side of the cord, and 
these cross at different levels in the anterior commissure of the 
cord lower down; hence the disappearance of the direct pyramidal 
tract in the lower part of the cord. 

3. Anterior Lateral Descending Tract. — An extensive tract, 
elongated but narrow, and reaching from the crossed to the direct 
pyramidal tract. It is a mixed tract, since not all of the fibres 
degenerate below the lesion. 

4. Comma Tract. — This is a small tract of fibres which degen- 
erate below section or injury of the cord. It is only found for 
a few millimetres below the actual lesion, though it degenerates 
downward; it is in reality a sensory tract, being composed of the 
branches of the entering posterior root-fibres which pass down- 
ward on entering the cord. 

Tracts of Ascending Degeneration. — 1. Goll. — This degenerates 
upward on injury or on section of the cord, as well as on section 
of the cord from below upward, and can be traced into the bulb. 
It is made up of very fine fibres. 

2. Direct Cerehellar Tract. — This tract is situated on the outer 
part of the cord between the crossed pyramidal tract and the 
margin. It is found in the cervical, thoracic, and upper lum- 
bar regions of the cord, and increases in size from below 
upward. It degenerates on injury or section of the cord itself, 
but not on section of the posterior nerve-roots. As its name 
implies, it passes up into the cerebellum. Its fibres are large, and 
originate from the cells of Clarke's column of the same side of 
the cord. 

3. Anterior Lateral Ascending Tract. — This tract is situated 
.'it the margin of the cord outside the corresponding descending 



AXATOMY, PHYSIOLOGY, AXD CHEMISTRY 15 

tract. Its fibres are of various sizes, and originate from cells 
situated in the base of the anterior horn of the opposite side of 
the spinal cord, and in the lower thoracic and lumbar regions ; the 
fibres pass through the gray matter or commissure and anterior 
horn of the opposite side, and travels up as the tract of Gowers to 
terminate above, principally in the cerebellum. 

4. Lissauers Tract. — This is a small tract of ascending fibres, 
situated at the outer side of the tip of the posterior cornu. It is 
made up of fibres of the posterior nerve-roots. 

Complete section of the spinal cord (transverse) leads to : 

(a) Loss of motion of the parts supplied by the nerves below 
the section on both sides of the body. The paralysis is not con- 
fined to the voluntary muscles, but includes the muscular fibres 
of the blood-vessels and viscera. Hence there is a fall of blood- 
pressure, paralysis of sphincters, etc. 

(h) Loss of sensation in the same regions. 

(c) Degeneration, descending and ascending, on both sides of 
the cord. 

Hemisection. — If the operation performed is not a r-omplete 
cutting of the spinal cord across transversely, but a cutting of 
half the cord across, it is termed hemisection. This operation 
leads to : 

(a) Loss of motion of the parts supplied by the nerves below 
the section on the same side of the body as the injury. 

(h) Loss of sensation in the same region. The loss of sensa- 
tion is not a very important symptom, and is limited to the sense 
of localization and the muscular sense. The animal can still feel 
sensations of pain and of heat and cold. 

(c) Degeneration, ascending and descending, nearly entirely 
confined to the same side of the cord as the injury. 

A lesion of the pyramidal tract in the cord may cause hemi- 
plegia or paralysis of one arm or leg. called monoplegia. 

When the motor decussation takes place in the anterior pyra- 
mids, it cuts oft' the anterior horns of the spinal cord, forming a 
number of nuclei which give origin to motor fibres of the cranial 
nerves. The posterior horns are cut oft by the decussation of the 
fillet and give sensory nuclei which form origins to the cranial 
nerves. 

Medulla Oblongata. — The medulla oblongata is the upper ex- 
pended part of the spinal cord. It connects the "upper part of the 



16 TEEATISE OX XEEYOUS DISEASES 

spinal cord with the pons varolii. The weight of the medulla is 
about 100 grains. In the medulla, the fibres from the cord are 
rearranged, the gray matter is also much changed, while new gray 
matter is added. Each half of the medulla consists of the follow- 
ing parts, from before backward: anterior pyramid, olivary body, 
restiform body, funiculus gracilis, and funiculus cuneofiis. By 
the divergence of the posterior columns and the restiform bodies, 
the floor of the fourth ventricle is formed. At "the anterior lower 
border of the medulla we find the decussation of the pyramids, 
where the fibres cross over to the lateral columns of the cord. 
The anterior pyramid receives the direct pyramidal tract of the 
anterior column of the cord from its own side, and the crossed 
p\Tamidal tract from the lateral column of the cord of the oppo- 
site side. Most of the pyramidal fibres pass through the pons 
directly to the cerebrum, a few fibres ^^assing to the cerebellum. 
The anterior -median fissure of the spinal cord terminates at the 
foramen caBCum, just beneath the pons. In transverse section at 
the level of the inferior olive we see the pyramids in front. Ex- 
ternal to the pyramid, on either side, is the inferior olive with its 
contained nucleus of gray matter called the dentate nucleus. The 
formatio reticularis is seen in the centre of the section, Formatio 
reticularis is an association system of short fibres which is to be 
met with at any point between the spinal cord and the thalamus. 
These fibres run at right angles to each other. Imbedded in it 
are nerve-cells. 

The restiform body is composed of fibres from the following 
sources : 

Erom the superior olive. 

Erom lateral nucleus. 

Erom the direct cerebellar tract of the same side. 

From the nucleus gracilis and nucleus cuneatus of the same 
side (posterior superficial arcuate fibres). 

From the nucleus gracilis and nucleus cuneatus of the opposite 
side (anterior superficial arcuate fibres). 

From lateral nucleus of opposite side. 

From the olivary nucleus by fibres which pass through the 
opposite olive, superficial to the opposite olive, and deeper than 
the opposite olive. 

The funiculus gracilis of the medulla is composed of fibre? 
which occupy the column of GoU in the spinal cord. 



AXATUMY, PHYSIOLOGY. AXD CHEMISTRY It 

The funiculus cuneatus is composed of fibres which occupy the 
column of Burdach in the spinal cord. 

The funiculus of Rolando is the continuation upward into the 
meduUa of the gelatinous substance capping the posterior horns 
in the spinal cord. 

The meduUa is about 1 inch in length, J of an inch in width, 
and J an inch in thickness. It has four faces. 

The triangular space between the restiform bodies is a part 
of the floor of the fourth ventricle. Eunning transversely across 
the floor of the fourth ventricle are a group of fibres which give 
partial origin to the auditory nerve. They form the "beard" 
of the fourth ventricle. Just at the divergence of columns* of 
GoU is the nib of the fourth ventricle, called the calamtis scrip- 
tor ins. 

Centres found in the Medulla. — Eespiratory, cardio-inhibitory, 
diabetic, deglutition, vaso-motor, cardio-accelerator, vomiting, 
salivation, mastication. 

Pons Varolii, Etc. — This is situated between the meduUa and 
the crura cerebri. It is a white body in the form of a half ring. 
Its size depends upon the size of the hemisphere with which it 
has to do. It weighs about 250 grains. It has six faces. The 
anterior face rests upon the basilar process of the occipital bone, 
and presents a median groove for the basilar artery. The posterior 
surface of the pons forms a part of the floor of the fourth ven- 
tricle. 

The pons is formed of scattered nerve-fibres and cells. The 
transverse fibres wMch form the cortex go for the most part 
through the cerebellar peduncles to the hemispheres. 

There are three planes of transverse fibres: first, the super- 
ficial, which covers the pyramidal columns ; second, the one known 
as the deep stratum, which separates the pvi*amidal tracts from the 
fillets; and the third, known as the complex, which separates the 
different tracts. On transverse section we see that the organ is 
divisible into an anterior portion or crusta, and a posterior por- 
tion or tegmentum. The superior olive is a collection of gray 
matter. The trapezium is a prominent group of transverse fibres 
running from the accessory nucleus and tuberculum acusticum to 
the superior olive situated in front of the tegmentum. Xumerous 
small masses of gray matter are found in the pons, which are 
known as the pontine nuclei. 



18 TREATISE OX X ER VOUS DISEASES 

The pons is a cross-way for the conduction of motion in one 
direction and sensation in the opposite; and besides this function 
of the pons there is a co-ordination centre in the pons for reflex 
actions. Irritation of the pons will cause convulsions; therefore 
it contains a convulsive centre. 

Cerebral Peduncles. — The cerebral peduncles extend from the 
superior part of the pons to the optic thalami, and their size is 
in direct relation with the size of the brain proper. The}^ are 
about f of an inch in length. After leaving the pons they are 
separated from each other, each going to the hemisphere of the 
respective sides. The space between them is known as the inter- 
peduncular space. The cerebral peduncles have an anterior face, 
which presents a longitudinal groove. The external face is em- 
braced in great part by the hippocampal convolution. 

Upon transverse section we see a black-looking structure which 
separates the crusta from the tegmentum and is known as the 
locus niger, dividing the pes or crusta from the "tegmentum. The 
tegmentum consists of masses of gray matter and fibres extending 
through the posterior end of the medulla oblongata, pons, and 
crura up to the optic thalami. The crusta is composed of two bun- 
dles, the internal or cortico-pontal, which goes to the anterior por- 
tion of the brain, and which might be considered as a commissure 
of the brain, connecting that portion with the gray nuclei in the 
medulla and pons and the cerebellum; and another, the external 
bundle or voluntary motion bundle, which comes from the ascend- 
ing frontal and ascending parietal convolutions, and ends in the 
anterior horns of the spinal cord. The external bundle contains the 
geniculate bundle. This starts in the cortex around the speech 
centre, and ends in the hypoglossal, facial, and trigeminal nuclei. 

In the peduncle is seen the nucleus ruber, which is composed 
of a mass of red fibres and cells, and in which ends the superior 
cerebellar peduncle. 

In the tegmentum of the peduncle are also sensory fibres. In 
the tegmentum are three masses of longitudinal fibres, viz., the 
posterior, the central, and superior. 

There are three fillets. The median or upper, which rises 
from Goll and Burdach's nuclei and runs on through the teg- 
mentum chiefly, and in lateral nucleus of optic thalamus, and 
then enters the cortex of the brain. The lateral fillet, which starts 
from Goll and Burdach's nuclei, runs to the superior olive and 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 10 

ends in the posterior corpus quadrigeminum. It is composed of 
fibres concerned in hearing. The mesial fillet comes from the 
same source as the others. It terminates in the base of cerebrum. 

Capsules of the Brain. — They are the internal and external. 
The internal capsule is composed of a band of white fibres, being 
divided into an anterior and a posterior segment. The point where 
the segments are united is known as the genu. The internal cap- 
sule is bounded internally by the optic thalamus and caudate nu- 
cleus, externally by the lenticular nucleus. The fibres composing 
the anterior segment of the internal capsule are the cortico-pontal 
fibres anteriorly and the geniculate tract posteriorly. In other 
words, the geniculate tract lies just in front of the genu. The 
posterior segment of the internal capsule is made up of motor 
fibres for its anterior two-thirds, and sensory for the posterior one- 
third. The motor tract has the following origin and distribution : 
From ascending frontal, ascending parietal convolutions (motor 
area), through anterior two-thirds of posterior segment of internal 
capsule, thence through crura, pons, anterior pyramids of medulla, 
and there decussate. Crossed pyramidal portion goes down oppo- 
site lateral column; direct pyramidal portion goes down the same 
side, both tracts ending finally in the anterior horns for further 
distribution. The sensory tract is traced as follows: From occip- 
ital, parietal, and temporal lobes, through posterior third of in- 
ternal capsule (posterior segment) into peduncle, divides, the 
main part goes through tegmentum to nuclei of Goll and Burdach, 
down posterior columns through ganglion of posterior root to 
skin. The rest or remainder of the sensory fibres go through the 
lateral columns for further distribution. 

The exterfial capsule is a band of fibres bounded laterally or 
internally by the lenticular nucleus and externally by the clau- 
strum. 

Cerebellum. — The cerebellum is composed of an elongated cen- 
tral portion or lobe, called the vermiform process, and two lateral 
hemispheres. Each hemisphere is connected with its fellow not 
only by means of the vermiform process, but also by a bundle of 
fibres called the middle peduncle (the latter forming the greater 
part of the transverse fibres of the pons), while the superior 
peduncles, which decussate in the mid-brain, connect it with the 
cerebrum, and the inferior peduncles (restiform bodies) connect it 
with the medulla oblongata. 



20 TREATISE ON^ NERVOUS DISEASES 

The cerebellum is composed of white and gray matter, the 
latter being external, like that of the cerebrum, and, like it, in- 
folded so that a larger area may be contained in a given space. 
The tree-like arrangement of the white matter has given rise to 
the name arbor vitce. Besides the gray matter on the surface, 
there are in the centre of the white substance of each hemisphere 
small masses of gray matter, the largest of which is called corpus 
dentatura. The others are called nucleus glohosus, nucleus fastigii, 
and nucleus emboliformis. 

If a section is taken through the cortical portion of the cere- 
bellum, the following distinct layers can be seen by the micro- 
scope. 

Underneath the pia mater is the external layer of gray matter ; 
it is formed chiefly of fine nerve-fibres with small nerve-cells scat- 
tered through it. Into its outer part processes of pia mater pass 
vertically; these convey blood-vessels. There are also here numer- 
ous long tapering neuroglia cells. The internal or granular layer 
of gray matter is made up of a large number of small nerve-cells 
mixed with a few larger ones, and some neuroglia cells. Between 
the two layers is an incomplete stratum of large flask-shaped cells 
called the cells of Purkinje. Each of these gives off from its 
base a fine process which becomes the axis cylinder of one of the 
medullated fibres of the white matter; the neck of the flask 
passing in the opposite direction breaks up into dendrites, which 
pass into the external layer of gray matter. Each cell of Pur- 
kinje is further invested by arborizations of two sets of nerve- 
fibres. One of these (originating from the fibres of the white 
matter which are not continuous as axis cylinders from the 
cells of Purkinje) forms a basket-work round the dendrons; the 
other (originating as axis-cylinder processes from the nerve-cells 
of the external layer) forms a felt-work of fibrils round the body 
of the cell. 

The cells of the internal layer of gray matter are small ; their 
dendrites intermingle with those of neighbouring cells; their ax- 
ones penetrate into the external layer, but their final destination is 
uncertain. Ramifying among these cells are fibres characterized 
by possessing bunches of short branches at intervals. 

Cerebrum. — The cerebrum consists of two halves called cere- 
bral hemispheres, separated by a longitudinal fissure and con- 
nected by a large band of transverse commissural fibres known as 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 21 

the corpus callosum. The interior of each hemisphere contains 
a cavity of complicated shape called the lateral ventricle. 

Each hemisphere is covered with gray matter, which passes 
down into the fissures that abound on its exterior. The amount 
of this gray matter varies directly with the amount of convolu- 
tions of the surface. Under it white matter is situated, and at 
the base there are masses of gray matter; parts of these basal gan- 
glia are seen forming part of the wall of the ventricles. The an- 
terior basal ganglion is called the corpus striatum; it is divided 
into two parts, called the lenticular nucleus and the caudate nu- 
cleus. The posterior basal ganglion is called the optic thalamus. 

Passing between the basal ganglia are the white fibres, which 
enter the cerebral hemispheres from the crus; these constitute the 
internal capsule (already explained). 

The brain cortex has four layers, as follows : 1, molecular 
layer, containing caudal cells; 2, layer of small pyramidal cells; 
3, layer of large pyramidal cells and cells of Martinotti whose 
axones run upward to the first or molecular layer; 4, layer of 
polymorphous cells. 

The outer or external surface of the brain presents numerous 
depressions and elevations, the latter being known as convolutions. 
Each cerebral hemisphere is divided into lobes, which are further 
divided by many depressions or -fissures into convolutions. The 
cause of folding of the cerebral substance is due to the rigidity 
of the cranium during development. 

There are five great fissures, viz., the great longitudinal, the 
great transverse, fissure of Sylvius, fissure of Eolando, and the 
occipito-parietal. 

The fissure of Rolando commences at the great longitudinal 
fissure, and runs downward, terminating above the horizontal limb 
of the fissure of Sylvius. 

The iveiglit of the brain is about 52 ounces. In rare cases it 
may reach 65 ounces. It is heavier in civilized than uncivilized 
races; greater in the male than in the female. 

Optic Thalami. — The optic thalami are about the size of pig- 
eons' eggs, and are directed obliquely forward and inward, and 
approach each other at their anterior extremities. Between them 
lies the third ventricle. 

The thalami have three nuclei, viz., external, or lateral nu- 
cleus of Flechsig, internal, and anterior. The lateral nuclei are 
2 



22 TREATISE OX NERVOUS DISEASES 

the points of attachment of the posterior roots. The other nuclei 
do not have anything to do with the posterior roots. 

There are some cells between the yulvinar and the origin of the 
peduncle of the inneal gland, called the hahenula. There is also 
a nucleus known as the nucleus of the hahenula. 

Corpora Quadrigemina, Etc. — These are four small bodies, sepa- 
rated from the aqueduct of Sylvius by the lamina quadrigemina. 
The anterior pair are connected by the superior brachia with the 
external geniculate bodies. The posterior pair are connected by 
the inferior brachia to the internal geniculate bodies. The anterior 
corpora quadrigemina are principally concerned in sight, while 
the posterior are concerned principally in hearing. 

Corpus Striatum. — This is so called from the fact that white 
fibres of the internal capsule pass through it. They are situated 
a little in front and slightly outward from the optic thalami. 
The nuclei composing these bodies, as before stated, are the lentic- 
ular and caudate. 

Membranes of the Brain and Cord. — The brain and spinal cord 
are enveloped in three membranes: 1, dui^a mater; 2, arachnoid; 
3, pia mater. 

1. The dura mater or external covering is a tough membrane 
composed of bundles of connective tissue which cross at various 
angles, and in whose interstices branched connective-tissue cor- 
puscles lie; it is lined by a thin, elastic membrane on the inner 
surface of which is a layer of endothelial cells. 

2. The arachnoid is a more delicate membrane, very simple, 
and similar in structure to the dura mater, and lined on its outer 
free surface by an endothelial membrane. 

3. The pia 7nater consists of two chief layers, between which 
numerous blood-vessels ramify. Between the arachnoid and the 
pia mater is a network of fibrous tissue trabeculas sheathed with 
endothelial cells; these subarachnoid trabeculxB divide up the sub- 
arachnoid space into a number of irregular sinuses. There are 
some similar trabeculae, but fewer in number, traversing the sub- 
dural space, i. e., the space between the dura mater and arachnoid. 

Section II. — Physiology 

Physiology of the Nervous System. — Functions of the Spinal 
Cord. — It is a great conducting medium, carrying impulses up- 



ANATOMY. IM[YS10L0(;Y, AND CHEMLSTKY 



2'3 



ward and downward, and within itself from side to side; it is the 
great reflex centre^ or rather series of so-called reflex centres. Im- 
pulses originate within it a function of minor importance, how- 
ever. 

Spinal Reflexes. — By reflex action or movement is meant a 
movement caused b}^ the stimulation of an afferent (sensory) 
nerve. The simplest definition is : a reflex action is an afferent 
impulse followed by an efferent impulse. Another definition is : 
a reflex act is the transmission of irritation by the neuraxone of a 
sensory neurone to the dendrones of the motor neurone, and by its 
neuraxone to the muscle. 

The stimulus, on being applied to an afferent nerve, sets up 
a state of excitement (nervous impulse) in that nerve, which 
state of excitement is transmitted or conducted in a centripetal 
direction along the nerve to the centre (spinal cord) ; where the 
nerve-cells represent the nei^ve-centre in the cord, the impulse is 
transferred to the motor, efferent, or centrifugal channel. Three 
factors, therefore, are essential for a reflex motor act — afferent 
flhre, a transferring centre, and an efferent fibre; these together 
constitute a reflex arc. 

In a purely reflex act all voluntary activity is excluded. Ke- 
flex movements may be divided into three classes, as follows : 

a. The simple or partial reflexes, which are characterized by 
the fact that stimulation of a sensory area discharges movement 
in one muscle only, or at least in one limited group of muscles. 

h. The extensive inco-ordinate reflexes, or reflex spasms. 
These movements occur in the form of clonic or tetanic contrac- 
tions ; individual groups of muscles, or all the muscles of the body 
may be implicated. 

c. Extensive co-ordinated reflexes are due to stimulation of a 
sensory nerve, causing the discharge of complicated reflex move- 
ments in whole groups of different muscles, the movements being 
'' purposive " in character, i, e., as if they were intended for a 
particular purpose. 

If an electric irritant is applied to a motor nerve there will 
be a grater contraction of the muscle than if the irritant was 
applied directly to the muscle itself. 

In reflex action are three elements : first, the external irrita- 
tion; second, excitation of nerve-centres themselves; third, con- 
tractions of the muscles. 



24 TREATISE 0^ NERVOUS DISEASES 

The seat of reflex action is mainly in the cord, although some 
centres are found in the medulla and pons varolii. 

' Pfliiger's Laws of Reflex Action. — 1. The reflex movement oc- 
curs on the same side on which the sensory nerve is stimulated, 
while only those muscles contract whose nerves arise from the 
same segment of the spinal cord. 

2. If the reflex occurs on the other side, only the corresponding 
muscles contract. 

3. If the contractions be unequal upon the two sides, then the 
most vigorous contractions always occur on the side which is 
stimulated. 

4. If the reflex excitement extend to other motor nerves, those 
nerves are always affected which lie in the direction of the me- 
dulla oblongata. Lastly, all the muscles of the body may be 
thrown into contraction. 

In the spinal cord reflex impressions pass at the rate of 20 
feet per second. 

Inhibition of the Reflexes. — Within the body there are mechan- 
isms which can suppress or inhibit the discharges of reflexes, and 
they may therefore be termed mechanisms inhibiting the reflexes. 
These are: 

1. Voluntary Inhibition. — Reflexes may be inhibited voluntar- 
ily, both in the region of the spinal cord and brain. Example: 
Keeping the eyelids open when the eyeball is touched; arrest of 
movement when skin is tickled. We must observe, however, that 
the suppression of the reflexes is possible only up to a certain 
degree. 

2. Setschenow's Inhihitoiij Centres. — They are located in the 
corpora quadrigemina and the optic thalami. 

3. Strong stimulation of a sensory nerve inhibits reflex move- 
ments. The reflex does not take place if an afferent nerve be 
stimulated very powerfully. Example : Suppressing a sneeze by 
friction of the nose; suppression of the movements produced by 
tickling, by biting the tongue. 

4. Poisons. — Chloroform diminishes the reflex excitability by 
acting upon the centres. " 

A constant current of electricity passed longitudinally through 
the cord diminishes the reflexes, especially if the direction of the 
current is from above downward. 

Some drugs affect the reflex excitability directly by acting on 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 26 

the spinal cord — e. g., methylconine — but other drugs may produce 
the same result indirectl}^ by affecting the heart and, the blood 
supply to the cord. If the abdominal aorta be compressed for a 
few minutes to cut off the blood supply to the cord and lower 
limbs, paraplegia is temporarily produced. Blood is absolutely 
necessary for the maintenance of function in the cord. If the sup- 
ply be cut off from the brain, the person will lose consciousness 
in four seconds. Anaemia will stimulate reflex actions for a cer- 
tain time. If the excitation is carried to a great degree the cord 
will become fatigued. If the spinal cord is cut in the lumbar 
region there will be a rhythmic action of the sphincters. Strych- 
nine is poisonous to every nerve-cell, while chloroform is poisonous 
to every cell both of plants and animals. 

According to Brown-Secjuard, reflex activity is most marked 
in birds, amphibians, reptiles, next in mammals and fishes. In 
the new-born it is always very great. 

The physician, by studying the condition of the reflexes, can 
form an idea as to the condition of (practically) every inch of the 
spinal cord. The following reflexes have been noted : 

1. Plantar Reflex. — Obtained by tickling the sole of the foot. 
Centre in the lumbar region. 

2. Patellar Reflex. — Obtained by striking the tendon above 
or below the patella. Centre between second and third lumbar 
nerves. 

3. Cremasteric Reflex. — Obtained by tickling or pinching the 
inside of the thigh; the testicle is drawn up. Centre in the lumbar 
region, between second and third lumbar nerves. 

4. Abdominal Reflex. — Obtained from a sharp push in the ab- 
domen, causing contraction of the abdominal muscles. Centre 
between eighth and twelfth dorsal nerves. 

5. Epigastric Reflex. — If the skin is excited between the fourth, 
fifth, and sixth intercostal spaces, there will be a contraction of 
the rectus abdominis. Centre between fourth and eighth dorsal 
nerves. 

6. Scapular Reflex. — On irritating the skin over the scapula 
there will be a contraction of the shoulder muscles. Centre be- 
tween seventh and eighth cervical and second dorsal nerves. 

7. Cilio-spinal Reflex. — If the skin of neck is pinched there 
will be a dilatation of the pupil. Centre between sixth cervical 
and third dorsal nerves. 



26 TREATISE OX XERVOUS DISEASES 

Other Keflex Centres in the Spinal Cord. — a. Ano-spirial cen- 
tre, or centre controlling the act of defecation. 

h. Vesicospinal centime for regulating micturition. 

c. Erection or genito-spinal centre, located in the lumbar re- 
gion. The afferent nerves are the sensory nerves of the penis; the 
efferent nerves for the deep artery of the penis are the vaso-dilator 
nerves arising from the first to the third sacral nerves. 

d. Ejaculation Centre. — The afferent nerve is the dorsal nerve 
of the penis; the centre lies at the fourth lumbar vertebra; the 
motor fibres of the vas deferens arise from the fourth to the fifth 
lumbar nerves, which pass into the sympathetic, and from thence 
into the vas deferens. The motor fibres for the bulbo-cavernosus 
]nuscle, which ejects the semen from the bulb of the urethra, lie in 
the third and fourth sacral nerves. 

e. Vaso-motor Centres. — Both vaso-constrictor and vaso-dilator 
centres are distributed throughout the whole of the spinal axis. 

/. Siueat Centres. — These are located in the spinal cord. 

g. Parturition Centre. — This lies at the first and second lumbar 
vertebra ; the afferent fibres come from the uterine plexus, to which 
also the motor fibres proceed. Goltz observed that a bitch became 
pregnant after its spinal cord was divided at the first lumbar 
vertebra. 

Excitability of the Spinal Cord. — Even at the present time ob- 
servers are by no means agreed whether the spinal cord, like the 
peripheral nerves, is excitable, or whether it is distinguished by the 
remarkable peculiarity chat most of its conducting paths and gan- 
glia do not react to direct electrical and mechanical stimuli. It 
is contended by most observers that if stimuli be cautiously ap- 
plied either to white or gray matter, there is neither movement 
nor sensation. As the spinal cord conducts to the brain impulses 
communicated to it from the stimulated posterior roots, but does 
not itself respond to stim.uli which produce sensations, Schiff has 
applied to it the term cesthesodic. Further, as the cord can con- 
duct both voluntary and reflex motor impulses without, however, 
itself being affected by stimuli applied to it directly, he called it 
hinesodic. 

The following views have been expressed: 

1. In the posterior columns the sensory root-fibres of the pos- 
terior root which traverse these columns give rise to painful im- 
pressions, but the proper paths of the posterior columns them- 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 27 

selves do not do so. Removal of the posterior column produces 
ancesthesia (loss of tactile sensation). Algesia (or the sensation 
of pain) remains intact, although at first there may even be 
hyperalgesia. 

The trophic centres of posterior roots are the posterior root 
ganglia. 

2. The anterior columns are non-excitable, both for striped 
and non-striped muscle, as long as the stimuli are applied only 
to the proper paths of these columns. But movements may follow 
either when the anterior nerve-roots are stimulated or when, by 
the escape of the current, the posterior columns are affected, where- 
by reflex movements are produced. 

The trophic centres of anterior roots are the anterior horns. 

3. The vaso-constrictor nerves, which proceed from the vaso- 
motor centre and run downward in the lateral columns of the 
cord, are excitable by all stimuli along their whole course; direct 
stimulation of any transverse section of the cord constricts all 
the blood-vessels below the point of section. In the same way, the 
fibres which ascend in the cord and increase the action of the vaso- 
motor centre are also excitable. Stimulation of these fibres, al- 
though it affects the vaso-motor centre reflexly, does not cause 
sensation. 

4. Chemical stimuli, such as the application of salt or wetting 
the cut surface with blood, appear to excite the spinal cord some- 
what. 

5. The motor centres are directly excited by blood heated to 
about 40° C, or by asphyxiated blood, or by sudden and complete 
anasmia of the cord produced by ligature of the aorta, and also 
by certain poisons. Picrotoxifi, nicotine, and compounds of bari- 
um seem also to produce the effect. 

Paths of Spinal Cord for Pain, Heat, and Cold; Muscular and 
Tactile Sensations. — Pain, heat, and cold impressions pass through 
the gray matter of the spinal cord from cell to cell. 

Muscular and tactile sensations are transmitted through or by 
the white matter of the cord. 

Vaso-motor nerves come down the lateral columns in the gray 
substance to the anterior roots. 

The nerves from the centre of respiration run through the 
lateral columns and then enter the gray substance of the anterior 
horns and leave by the anterior roots. 



28 TREATISE 0^ XEEVOUS DISEASES 

The siveat and inhibitory fibres running down the lateral col- 
umns both decussate, the former in the cord and the others in 
the medulla. The sweat fibres pass out from the anterior roots, 
also the branches which make up the splanehnics. 

There is one sensory decussation in the fillet fibres. 

There are two motor decussations : the lower one is in the cord, 
in the anterior commissure, while the higher is in the anterior 
pyramids. 

Locomotor Ataxia. — In locomotor ataxia there is a degenera- 
tion of the lower part of the posterior column. Tactile and mus- 
cular sensations are abolished. Pain, heat, and cold sensations, 
however, are still transmitted, as a rule. 

Syringomyelia. — This is a disease of the gray tract, with 
gliosis and final cavity formation. Sensations of heat, pain, and 
cold are abolished, while tactile and muscular sensations are still 
transmitted. 

When there is a lesion in the pons, there is a paralysis of the 
face on one side and of the arm and leg on the opposite side. 
This is known as crossed hemiplegia. 

Monoplegia is paralysis of certain areas alone, as in the leg, 
arm, etc., due to haemorrhage in the brain or disease of certain 
parts of the motor area. 

There is a plentiful supply of blood-vessels in all portions of 
the brain. Both the caudate and lenticular nuclei are supplied by 
the middle cerebral artery. There are three lenticular branches; 
one of these is known as the lenticulo-striate artery of cerebral 
hcemorrhage. It is sometimes called Charcot's artery of cerebral 
haemorrhage. 

The brain has no true lymphatics, but both in the brain and cord 
are the perivascular lymph spaces of His which carry the lymph. 

Nerve-Fibres, Function of. — A nerve wave is a transmission of 
nerve force through the axis cylinder of a nerve. This brings out 
the properties of nervous excitability. The laws of nervous con- 
ductivity are : First, the integrity of the nerve; the neuraxone must 
be intact. Second, isolated conduction ; a nerve-fibre carries an im- 
pression without its being diffused to other nerves. Third, the law 
of conduction in both directions; if a nerve is irritated, the im- 
pression may be carried both ways. 

Sensory and motor nerves are of the same nature and structure, 
but they are attached to different forms of apparatus. 



A^^ATOMY, PHYSIOLOGY, AND CHEMISTRY 29 

Electricity travels ten million times faster than nerve waves. 

Irritability is a fundamental property of nerves. After a nerve 
is cut and separated from the circulation, it will retain its irrita- 
bility for some time, but eventually loses it. The Esmarch bandage 
will cause this phenomenon. When a nerve is cut, the first thing- 
is a rise of irritability, soon followed by its loss. Woorara para- 
lyzes the terminations of the motor nerves in the muscles. In sym- 
metrical gangrene there is a slow stoppage of the circulation, and 
the pain is very acute. The patient suffers first from hyperaes- 
thesia, but this soon disappears. When a mixed nerve is irritated, 
there is first an anaesthesia and then a paralysis. Heat causes nerv- 
ous excitability and cold renders a part insensible, and if carried 
to excess causes temporary paralysis. Inflammation causes great 
irritation to the nerves. When such nerves are incised there is 
much more pain than in healthy tissue. ISTerves possess the prop- 
erty of being thrown into a state of excitement by stimuli, and are 
therefore said to be excitable. The stimuli may be applied to and 
may act upon any part of the nerve. The following are the various 
kinds of stimuli — i. e., modes of motion — which act upon the 
nerves : 

1. Mechanical stimuli act upon nerves when they are applied 
with sufficient rapidity to produce a change in the form of the 
nerve particles, such as pressure, pinching, tension, puncture, etc. 
In the case of sensory nerves, when they are stimulated pain is 
produced, as is felt when a limb " sleeps,'' or when pressure is ex- 
erted upon the ulnar nerve at the bend of the elbow. When a 
motor nerve is stimulated, motion results in the muscle attached 
to the nerve. . If the continuity of the nerve-fibres be destroyed, the 
conduction of the impulse across the injured part is interrupted. 
Continued pressure upon a mixed nerve paralyzes the motor fibre 
sooner than the sensory fibres. 

2. Tliermal Stimuli. — If a frog's nerve be heated to 45° C, its 
excitability is first increased and then diminished. The higher the 
temperature, the greater is the excitability and the shorter is its 
duration. If a nerve be heated to 50° C. for a short time, its 
excitability is abolished as well as its conductivity. Sudden cooling 
of a nerve to 5° C. ^cts as a stimulus, causing contraction in a 
muscle. 

3. Chemical Stimuli. — These excite nerves when they act with 
a certain rapidity and thereby alter the condition of the nerve. 



30 TEEAT18E OiNT NEEVOUS DISEASES 

Most chemical stimuli act by first increasing the nervous excita- 
bility and then diminishing or paralyzing it. Chemical stimuli, as 
a rule, have less effect upon the sensory than upon the motor fibres. 
The following chemical stimuli excite nerves : alkaline salts, sugar, 
urea, glycerin, and some metallic salts. Atropine diminishes the 
action of the pneumogastrics and the glandular nerves, etc. Pilo- 
carpine has the opposite action. Free alkalies, mineral acids 
(not phosphoric), acetic, oxalic, tartaric, and lactic acids dimin- 
ish the excitability of nerves, as well as most salts of the heavy 
metals. 

4. Physiological or normal stimuli excite the nerves in the 
normal body. Its nature is entirely unknown. The " nerve 
motion " thereby set up travels either in a '' centrifugal " or out- 
going direction from the central nervous system, giving rise to 
motion, inhibition of motion, or secretion, or in a " centripetal " 
or ingoing motion or direction from the specific end organs of the 
nerves of the special senses or the sensory nerves. 

5. Electrical Stimuli. — The following forms of electrical stim- 
uli may be used: a. A constant current, which may be made or 
broken, h. Induction sliochs, either make or break shocks, c. An 
interrupted current. 

Constant Current. — If the constant current be used as a nerve 
stimulus, the stimulating effect on the sensory nerves is most 
marked at the moment of making and breaking the current; dur- 
ing the time the current passes only slight excitement is perceived, 
but even under these circumstances very strong currents may 
cause very considerable, and even unbearable, sensations. If a 
constant current be applied to a motor nerve, the greatest effect 
is produced when the current is made or closed and when it is 
broken or opened. But while the current is passing, the stimu- 
lation does not cease completely; for, with a certain strength of 
stimulus the muscle remains in a state of tetanus. 

An irritation of sensory nerves, except nervous depressor, pro- 
duces increase of blood pressure. 

Induction Current or Blioch. — If a galvanic element is closed 
by means of a short arc of wire, at the moment the circuit is again 
opened or broken a slight spark is noticed. If, however, the cir- 
cuit is made or closed by means of a very long wire rolled in a 
coil, then, on breaking the circuit, there is a strong spark. If the 
wires be connected to two electrodes, so that a person can hold 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 31 

one in each hand, the current at the moment it is opened must 
pass through the person's body — then there is a violent shock 
communicated to the hand. This phenomenon is due to a current 
induced in the long spiral of wire which has been called the 
extra current. 

Interrupted or Faradic Current. — If a very long insulated 
wire be coiled into the form of a spiral roll, which is called the 
secondary spiral, and if a similar spiral, the primary spiral, be 
placed near the former, and the ends of the wire of the primary 
spiral be connected with the poles of a constant battery, every 
time the current in the primary circuit is made (closed), or broken 
(opened), a current takes place, or, as it is said, is induced, in the 
secondary spiral. If the primary circuit be kept closed, and if the 
secondary spiral be brought nearer to or removed farther from the 
spiral (primary), a current is also induced in the secondary spiral. 
The current in the secondary circuit is called the Faradic current. 
When the primary circuit is closed, or when the two spirals are 
brought nearer each other, the current in the secondary spiral has 
a direction opposite to that in the primary spiral, while the cur- 
rent produced by opening the primary circuit or by removing the 
spirals farther apart has the same direction as the primary. Dur- 
ing the time the primary circuit is closed, or when both spirals 
remain at the same distance from each other, there is no current 
in the secondary spiral. 

When a galvanic current is passed through a nerve, it is said 
to be in a state of electrotonus, because its irritability is modified. 
In this condition, the vital properties of the nerve are modified — 
i.e., its electro-motivity, its excitability. 

If a nerve be so arranged upon the electrodes that its trans- 
verse section lies on one and its longitudinal on the other elec- 
trode, then the galvanometer indicates a strong current. If, now, 
a constant current be transmitted through the end of the nerve 
projecting beyond the electrodes, and if the direction of the cur- 
rent coincides with that in the nerve, then the magnetic needle 
gives a greater deflection, indicating an increase of the nerve 
current — the positive phase of electrotonus. The increase is 
greater the longer the stretch of nerve traversed by the current, 
the stronger the galvanic current, and the less the distance be- 
tween the part of the nerve traversed by the constant current and 
that on the electrodeSo 



S2 TREATISE OX XERYOUS DISEASES 

If in the same length of nerve the constant current passes in 
the opposite direction to the nerve current, there is a diminution 
of the electro-motive force of the latter — negative phase of elec- 
tro tonus. 

If two points of the nerve equidistant from the equator be 
placed on the electrodes, there is no deflection of the galvanometer 
needle. If a constant current be passed through one free pro- 
jecting end of the nerve, then the galvanometer indicates an elec- 
tro-motive effect in the same direction as the current (constant). 

These experiments show that a constant current causes a 
change of the electro-motive force of the part of the nerve in- 
directly traversed by the constant current — i. e., in the intra- 
polar area — and also in the part of the nerve outside the elec- 
trodes — i. e., in the extrapolar area. This condition is called 
electrotonus. 

Muscle Current during Electrotonus. — The constant current 
also produces an electrotonic condition in the muscle; a constant 
current in the same direction increases the muscle current, while 
one in an opposite direction weakens it, but the action is rela- 
tively feeble. 

Cause of Electrotonus. — If a certain stretch of a living nerve 
be traversed by a constant electrical current, it passes into a con- 
dition of altered excitability which is known as electrotonus. This 
condition of altered excitability extends not only over the part 
actually traversed by the current, but it is communicated to the 
entire nerve. At the positive pole or anode the excitability is 
diminished; this is the region of anelectrotonus. At the negative 
pole or cathode the excitability is increased; this is the region of 
cath electrotonus. The changes of excitability are most marked in 
the regions of the poles themselves. 

Transmission of Nervous Impulses. — If a motor nerve be stimu- 
lated at its central end (1) a condition of excitation is set up, 
and (2) an impulse is transmitted along the nerve to the mascle 
with a certain velocity. The latter depends upon the former and 
represents the function of conductivity. According to Helmholtz 
the velocity for a human motor nerve-wave is about 100 feet per 
second. 

In the sensory nerves of man. the velocity of the impulse is 
probably about the same as in motor nerves. The rates usually 
given are about 150 feet per second. 



AXATOMY, PHYSIOLOGY, AXD CHEMISTRY 33 

Relay Stations of Motor and Sensory Fibres. — The optic thai- 
ami are the relay stations of the sensory tract. 

The caudate nuclei are the relay stations for the motor tract. 
Chemical and Mechanical Properties of Nervous Substance. — 

Specific gravity of white substance, 1.040; gray substance, 1.050. 
The reaction is sometimes slightly alkaline and sometimes slightly 
acid. It contains a varying amount of water and solid substances ; 
To per cent water and 25 per cent solid matter is about the 
average. 

P rote ids. — Albumin occurs chiefly in the axis cylinder and in 
the substance of the ganglionic cells. Some of this proteid sub- 
stance represents characters not unlike those of myosin. Dilute 
solution of common salt extracts a proteid from nervous matter, 
which is precipitated by the addition of much water and also by 
a concentrated solution of common salt. Potash alhwnin and a 
glohulin-liJce substance are also present. Xuclein occurs especially 
in the gray matter, while neuro-heratin, a body containing much 
sulphur and closely related to keratin, occurs in the neuroglia. 

Fats and other allied substances soluble in ether, more espe- 
cially in the white matter : 

a. Cerehrin, free from phosphorus. It is a white powder com- 
posed of spherical soluble granules (in hot alcohol and ether), 
but insoluble in cold water. When boiled for a long time with 
acids, it splits up into a left rotatory body like sugar and another 
unknown product. 

6. Lecithin and its decomposition products — glycero-phosphoric 
acid and oleo-phosphoric acid. 

c. Protagon, which contains nitrogen and phosphorus, is sim- 
ilar to cerebrin and lecethin combined. 

d. Leucin, inosite, etc. 

The physical properties of nerve tissue are cohesion and elas- 
ticity. 

Physiology of the Cerebellum. — Irritation of the cerebellum 
will cause no contractions or pain, but if it bo deeply injured 
there will be a tottering of the animal called a cerebellar tottering. 

If the cerebellum is entirely removed the animal will live 
for quite a time, and will soon learn to co-ordinate its movements. 
The cerebellum is the centre of co-ordination of muscular move- 
ments. It is probable that the co-ordinating fibres go through 
the descendino" antero-lateral tract. 



34 TKEATISE ON NERVOUS DISEASES 

Irritation of the cerebellum will not only cause a tottering 
walk, but also may cause a tendency to vomit, on account of the 
irritation of the vomiting centre in the medulla. Injury of the 
middle cerebellar peduncle causes a tendency for the animal to 
go to one side (circus movements). It also brings on internal 
squint on the same side and superior squint on the opposite side. 

Lesions of one hemisphere may not give rise to any symptoms; 
but if the middle lobe is involved, there is inco-ordination of move- 
ments, especially a tendency to fall, unsteady gait, and pronounced 
vertigo. Irritative lesions of the middle peduncle cause complete 
gyrating movements of the body around its axis, together with 
rotation of the eyes and head. 

Functions of the Medulla Oblongata. — The medulla oblongata, 
which connects the spinal cord with the brain, has many points 
of resemblance with the former. Like the cord, it is concerned 
in the conduction of impulses. In it numerous reflex centres are 
present — e. g., for simple reflexes similar to the nerve-centres in 
the spinal cord. There are other centres present which seem to 
dominate or control similar centres placed in the cord — e. g., the 
great vaso-motor centre, pupil-dilating centres, and the centre for 
combining the reflex movements of the body. Some of the centres 
are capable of being excited reflexly. It is also said to contain 
automatic centres. The normal functions of the centres depend 
upon the exchanges of blood and gases effected by the circulation 
of the blood through the medulla. If this gaseous exchange be 
interrupted or interfered with — as asphyxia, sudden anaemia, oi* 
venous congestion — these centres are first excited, and exhibit a 
condition of increased excitability, and at last, if they are over- 
stimulated they are paralyzed. An excessive temperature also acts 
as a stimulus by an action on the polypnoeic centre in the tuber 
cinereum which drives the respiration centre into activity. All the 
centres, however, are not active at the same time, and they do not 
all exhibit the same degree of excitability. Normally, the respira- 
tory centre and the vaso-motor centre are continually in a state 
of activity. 

The centres found in the medulla have been given under the 
anatomy of same. 

The respiratory centre lies in the medulla behind the super- 
ficial origin of the vagus, on both sides of the posterior aspect 
of the apex of the calamus seriptorius. between the nuclei of the 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 35 

vagus and accessorius. It consists of two parts, which are in a 
state of activity alternately, an Inspiratory and an expiratory, 
each one forming the motor central point for the acts of inspira- 
tion and expiration. Some observers claim that this is an auto- 
matic centre, for after section of all the sensory nerves which 
can act reflexly upon the centre, it still retains its activity. The 
degree of excitability and the stimulation of the centre depend 
upon the state of the blood, and chiefly upon, the amount of 
blood gases. 

The Cardio-inhibitory Centre. — The fibres of the vagus, when 
moderately stimulated, diminish the action of the heart; when 
strongly stimulated, however, they arrest its action and cause it 
to stand still in diastole; they are supplied to the vagus through 
the spinal accessory nerve, and have their centre in the medulla 
oblongata. Gaskell has shown that stimulation of the vagus not 
only influences the rhythm of the heart's action, but modifies the 
other functions of the cardiac muscle. Stimulation of the vagus 
influences the automatic rhythm — i. e., the rate at which the heart 
contracts automatically; the force of the contractions, more espe- 
cially the auricles, although in some animals — e. g., the tortoise — 
the ventricles are not affected; the power of conduction — i. e., the 
capacity for conducting the muscular contractions. This centre 
may be excited directly in the medulla, and also reflexly by stimu- 
lating certain efferent nerves. Stimulation of the trunl' of the 
vagus from the centre downward^ along its whole course, and also 
of certain, of its cardiac branches, causes the heart either to beat 
more slowly or arrests its action in diastole. The result depends 
upon the strength of the stimulus employed; feeble stimuli slow 
the action of the heart, while strong stimuli arrest it in diastole. 

Cardiac-Accelerating Centre. — This centre is also located in the 
medulla oblongata, which sends accelerating fibres to the heart. 
They pass from the medulla through the spinal cord, and leave 
the cord through the rami communicantes of the lower cervical 
and upper six dorsal nerves to pass into the sympathetic system. 
If the vagi of an animal be divided, stimulation of the medulla 
oblongata, of the lower end of the divided cervical spinal cord, 
even of the lower cervical ganglion, or of the upper dorsal gan- 
glion of the sympathetic, causes acceleration of the heart-beats in 
the dog and rabbit without the .blood-pressure undergoing any 
change. The inhibitory fibres of the vagus lose their excitability 



36 TBEATISE OX NERVOUS DISEASES 

more readily than the accelerating fibres, but the vagus fibres are 
more excitable than those of the accelerans. 

Vaso-motor Centre and Nerves. — The chief dominating centre, 
which supplies all the non-striped muscles of the arterial system 
with motor nerves, lies in the medulla oblongata at a point which 
contains ganglionic cells. The nerves passing from this centre are 
known as the vaso-motor nerves, there being two kinds of them — 
vaso-constrictor and vaso-dilator. The vaso-constrictor nerves, 
as their name implies, constrict the arteries, or rather reduce their 
mean diameters, thus causing an increase of blood-pressure, result- 
ing in the swelling of veins and the heart. The vaso-dilator nerves, 
as their name implies, cause a dilatation of the arteries and a de- 
crease in blood-pressure. 

Functions of the Pons Varolii. — This is seated in front of the 
medulla, and is the centre of convulsive movements. In epi- 
lepsy there is a lesion of the cortex of the brain, and the im- 
pressions are conveyed to the convulsive centre. It is also a path 
for the conduction of sensibility and motion. If there is a lesion 
in the pons, there is a paralysis of the face on one side and of 
the leg and arm of the opposite side. This is due to a lesion helow 
the facial decussation and above the motor decussation of the 
fibres in the pons. The convulsion centre can be excited by ex- 
cess of carbonic acid, lack of oxygen, anaemia, etc. 

Functions of Cerebral Peduncles. — They are about f of an inch 
in length, and contain fibres which connect the brain with the 
structures at its base. In the locus niger there is located the 
high detrusor centre of the bladder, although the proper detrusor 
centre is located down in the cord. 

Injury to one cerebral peduncle causes, in the first place, violent 
pain and spasm of the opposite side, w^hile the blood-vessels on 
that side contract and the salivary glands secrete. These phenom- 
ena of irritation are followed by paraMic symptoms of the oppo- 
site side — viz., anaesthesia and paresis. In afl;ections of tlie cerebral 
peduncle in man, we must remember the relation of the oculomo- 
torius to it, as the latter is often paralyzed on the same side, while 
the extremities, tongue, and half the face are paralyzed on the 
opposite side from the lesion. 

Functions of the Corpora 0.uadrigemina. — Destruction of these 
bodies on one side in mammals causes actual blindness, which 
may be on the same or the opposite side, according to the relation 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 37 

of the fibres crossing at the optic chiasm. Total destruction causes 
blindness of both eyes. At the same time, the reflex contraction 
of the pupil, due to the stimulation of the retina Avith light, no 
longer takes place where the optic is the afferent and the oculo- 
motorius the efferent nerve. If the cerebral peduncles are left in 
position and the cerebral hemisphere alone be removed, the pupil 
still contracts to light, as well as after mechanical stimulation of 
the optic nerve. Destruction of the corpora quadrigemina inter- 
feres with the complete harmony of the motor acts; disturbance 
of equilibrium and inco-ordination of movements occur. 

In man very little is known regarding the effects of disease 
of the corpora quadrigemina, interference with the ocular mus- 
cles being the most marked symptom; but the inco-ordination of 
movement which has been observed may be due to pressure upon 
the superior cerebellar peduncle, while it is by no means certain 
that the defects of vision are directly due to lesions of these 
bodies. 

Forced Movements. — It is evident from what has been said 
regarding the importance of the corpora quadrigemina for the 
harmonious execution of movements, that unilateral injury of such 
parts as are connected with them by conducting channels must 
give rise to peculiar unilateral disturbance of the equilibrium, 
causing variations from the symmetrical movements of both sides 
of the body. These are called ^^ forced movements.'^ 

Strabismus and Nystagmus. — Among the forced movements 
ma}^ be reckoned deviation of the eyeballs, strabismus or squinting, 
and involuntary oscillation of the e3^eballs, constituting nystagmus. 
The latte'r condition occurs after superficial lesions of the resti- 
form bodies, as well as of the floor of the fourth ventricle. 

Contraction centre of iris is in the anterior corpora quadri- 
gemina. 

Functions of the Corpora Striata. — Lenticular and Caudate Nu- 
clei. — Electrical stimulation of these nuclei causes general con- 
tractions in the opposite half of the body which are due to simul- 
taneous stimulation of the neighbouring cortico-muscular paths. 
There is no sign of pain. Lesions of the lenticular nucleus or of 
the caudate nucleus do not seem to give rise to any permanent 
symptoms, provided the internal capsule is not injured. If the 
corpus striatum is destroyed on one side, there is paralysis of the 

opposite side of the body. This bodv holds the same relation to 
3 



38 TREATISE OX XERVOUS DISEASES 

the motor tract that the optic thalami bear to the sensory tracts; 
on the other hand, or in other words, the corpora striata are the 
relay stations of the motor tracts. These bodies also contain a 
thermogenic centre, and if section is made of both the temperature 
will rise to 110.5° F. If section be made of the tuber cinereum 
there will be a great increase of temperature. 

Functions of Optic Thalami. — Ferriei* did not observe any 
movements on stimulating the optic thalami with electricity. As 
the pulvinar or the posterior extremity of the optic thalamus is in 
part the origin of the optic nerve, and is also connected by fibres 
with the cerebral cortex, it is probably related to the sense of 
sight. Injury to its posterior third in man results in disturbance 
of vision. Terrier surmises that the sensory fibres pass through 
the optic thalami on their way to the cortex, so that when they 
are destroyed insensibility of the opposite half of the body is 
produced. Thus these bodies are called relay stations for the 
sensory tracts. 

The Capsules: Functions, Etc. — In connection with the func- 
tions of the basal ganglia it is most important to remember their 
relation to the internal capsule. The anterior segment of the 
internal capsule sweeps between the caudate and lenticular nuclei, 
while the posterior segment lies between the optic thalamus and the 
lenticular nucleus. External to the first division of the lenticular 
nucleus is the external capsule, whose function is unknown. Ex- 
ternal to this latter structure is the claustrum, whose function 
also is unknown. It is evident that haemorrhage into or about the 
basal ganglia is apt to involve the fibres of the internal capsule. 
When the ^^ artery of haemorrhage '' ruptures it may not only 
destroy the lenticular nucleus, but the internal capsule will be 
compressed, and the same is the case with the I enticulo -thalamic 
artery — the external capsule will tend to force the blood inward. 
We know that in the posterior segment of the capsule the voli- 
tional or pyramidal fibres lie in the following order from before 
backward: those for the face (and tongue) in the knee; in the 
anterior third, those for the arm and hand; and in the middle 
third, for the leg, and perhaps behind these those for the trunk; 
so that a very small lesion in this region will affect a large num- 
ber of these fibres, converging as they do like the rays of a fan 
from the motor cortical areas, where the arrangement of these 
centres is a supero-inferior one, to become an antero-posterior one 



ANATOMY, PHYSIOLOGY, AND CHEMLSTKY 39 

in the knee and posterior limb of the internal capsule. The pos- 
terior third of this limb is sensory, and is the sensory cross-way. 

Destruction of the internal capsule causes paralysis of motion 
or sensibility, or both, on the opposite side of the body, according 
to the part of it which is injured. 

Functions of Cerebral Hemispheres. — Tlie cortical motor areas 
for the face, arm, and leg are grouped around the fissure of Ro- 
lando, including the ascending frontal, ascending parietal, and 
paracentral lobules. The centre for tlie face occupies the lowest 
third of the ascending frontal convolution, and reaches also to 
the lowest fifth of the ascending parietal. The arm centre occu- 
pies the middle third of the ascending frontal and middle three- 
fifths of the ascending parietal convolutions, while the leg centres 
lie at the upper end of the sulcus and extends backward into the 
parietal lobule. The leg centre is continued over on to the para- 
central lobule, opposite the upper ejid of the fissure of Rolando, 
in the marginal convolution on the mesial aspect of the hemi- 
sphere, where the centres for the muscles of the trunk also exist. 
The motor areas are supplied by branches of the S3dvian artery. 

To locate the fissure of Bolando on the cranium, a line is 
drawn from the glabella to the external occipital protuberance. 
Divide the distance into two equal parts, and -J an inch behind 
the middle point is the top of the fissure of Rolando. 

The cortical sensory areas are distributed very irregularly. 
There must be some connection between the surface of the brain 
and the afferent channels through which sensory impulses pass 
inward ; and although the channels for these impulses are, perhaps, 
not so well known, it must be that sensory impulses for the opposite 
half of the body travel upward through the posterior third of the 
posterior limb of the internal capsule, to radiate in all probability 
into the occipital, temporal, and parietal lobes. Parts of these 
different convolutions are sometimes spoken of as sensory centres. 

Extirpation and stimulation are the methods employed to de- 
termine the different areas on the brain. 

Heniiplegiii consists of motor paralysis of one-half of the body, 
although, as a rule, all the muscles are not paralyzed to the same 
extent; in some there may be complete paralysis — i. e., they are 
entirely removed from voluntary control — while in others there 
is merely impaired voluntary control. It may be caused by affec- 
tions of the cortical areas or bv lesion of the motor tracts above 



40 TEEATISE 0^" NERA^OUS DISEASES 

the medulla ; and the paralysis is always on the side opposite to the 
lesion, owing to the decussation of the motor paths in the medulla. 
If the case be a severe one, there is a complete hemiplegia due to 
lesion of the cortical centres for the face, arm, and leg. While 
the arm and leg are completely paralyzed, the lower part of the 
face is more affected than the upper half, w^hich is usually not 
affected. The arm recovers more quickly than the leg. 

Conjugate deviation of the eyes, with rotation of the head, 
is frequently present in the early period of hemiplegia, although 
it usually disappears. When a person turns his head to one side 
there is an associated movement of certain of the ocular muscles 
with those of the neck. The head and eyes are usually turned to 
the side of lesion; this is termed conjugate deviation, so that 
the power of voluntarily moving the eyes and head to the para- 
lyzed side is temporarily lost. The unopposed muscles rotate the 
head and eyes to the sound side. If a lesion be in the posterior 
part of the pons, the deviation is to the paralyzed side. 

Irritation of the Motor Centres. — If the motor centres are irri- 
tated by pathological processes, such as hyperaemia, inflammation 
in a syphilitic diathesis, tumours, tubercles, cysts, fragments of 
bone, etc., there arise spasmodic movements in the corresponding 
muscle groups. This condition of a sudden discharge of the gray 
matter resulting in local spasms is called Jacksonian cerebral 
epilepsy. 

The Centre of Speech. — The investigations of Broca and others 
have shown that the third left frontal coAvolution of the cerebrum 
{Broca's area) is of essential importance for speech, while prob- 
ably, the island of Eeil is also concerned. 

Three activities are required for speech : ( 1 ) the normal move- 
ment of the vocal apparatus; (2) a knowledge of the signs for 
objects and ideas; (3) the correct union of both. 

Aphasia. — Injury of the speech centre causes either a loss or 
more or less considerable disturbance of the power of speech. The 
loss of the power of speech is called aphasia. Aphasia, as usu- 
ally understood, means the partial or complete loss of the power 
of articulate speech from cerebral causes. A person may compre- 
hend what he sees or hears, yet he is unable to speak. 

Ataxic Aphasia. — Here there is loss of speech owing to inability 
to execute the various movements of the mouth necessary for speech 
and co-ordinated grimaces. He can utter inarticulate words or 



ANATOMY, PHYSIOLOGY, AND CIIEMJSTKY 41 

sounds. The muscles concerned in articulation are not paralyzed, 
but there is an absence of co-ordination of these muscles due to dis- 
ease of the cortical centre. Hence the patient cannot repeat what 
is said to him. Nevertheless, the psychical processes necessary for 
speech are completely retained, and all words are remembered ; and 
hence these persons can still give expression to their thoughts 
graphically by writing. If, however, the finely adjusted movements 
necessary for writing are lost, owing to an affection of the centre 
for the hand, then there arises at the same time the condition of 
agraphia, or inability to execute those movements necessary for 
writing. Such a person, when he desires to express his ideas in 
writing, only succeeds in making a few unintelligible scrawls on 
the paper. 

In word Nindness, the person cannot name a letter or a word, 
so that he cannot understand symbols, such as printed or written 
words, or it may be a familiar object; although he can see quite 
w^ell, while he can speak fluently and write correctly. 

In tvord deafness, the person hears other sounds and is not deaf, 
but he does not hear and understand words. (See Aphasia.) 

An animal or person can live with only one cerebral hemisphere 
intact; but if both are removed, the animal lies still, remaining 
in. one position, and will not move. 

Seats or centres of consciousness and volition (will) are lo- 
cated in the cerebral cortex. 

The cerebrum contains the centres of intelligence. There are 
many wa3^s of measuring the grade of intelligence of a man; the 
important is the facial angle measurement, explained as follows: 
The facial angle (Camper) is the divergence between a line drawn 
from the inferior anterior nasal ridge of upper jaw to the gla- 
bella, and another drawn from the nasal ridge to the external audi- 
tory meatus. In the Caucasian race it is 80° ; in the Mongolian, 
75° ; in the Ethiopian, 70°; and in apes, 40°. 

The Visual Centre. — According to Munk, this includes the 
occipital lobes {cuneus), while, according to Ferrier, it also in- 
cludes the angular gyrus. In cases of long-standing blindness 
there has been noticed to be a consecutive disappearance of the 
occipital convolutions on both sides of the parieto-occipital fis- 
sure. Stimulation of the centre gives rise to the phenomena of 
light and colour. Injury causes a disturbance of vision, especially 
hemiopia of the same side, to be further explained under the eye. 



42 TKEATISE OX NEEA'OUS DISEASES 

When one centre is the seat of irritation, there is a photopsia of 
the same halves of both eyes. Stimulation of both centres causes 
the occurrence of the phenomena of light or colour or visual 
hallucinations in the entire field of vision. 

The auditory centres are found in the superior temporal con- 
volutions. When this is completely removed, deafness is the re- 
sult, vs^hile partial injury causes psychical deafness. It has been 
found that softening of the first temporal convolution is the cause 
of these phenomena. 

The centres of taste and smell are located in the gyrus unci- 
natus. 

The centre of tactile sensihility is located in the gyrus forni- 
catus, according to some observers ; by others, in the motor area. 

Sleep and Waking. — In sleep and waking we observe the peri- 
odicity of the active and passive conditions of the brain. During 
sleep there is diminished excitability of the whole nervous system, 
which in turn is partly due to fatigue of the afferent nerves, though 
largely due to the condition of the central nervous system. During 
sleep we require to apply strong stimuli to produce reflex acts. 
In the deepest sleep the mental processes seem to be completely 
in abeyance, so that a person asleep might be compared to an ani- 
mal with its cerebral hemispheres removed. Towards the approach 
of the period when a person is about to waken, psychical activity 
may manifest itself in the form of dreams^ which differ, however, 
from normal mental processes. They consist either of impressions, 
where there is no objective cause, or of voluntary impulses which 
are not executed, or trains of thought where the reasoning and 
judging powers are disturbed. Often, especially near the time 
of waking, the actual stimuli may so act as to give rise to im- 
pressions which become mixed with the thoughts of a dream. 
The pupils are contracted during sleep in proportion to its depth ; 
so that in the deepest sleep they do not become contracted on 
the application of light. The pupils dilate when sensory or audi- 
tory stimuli are applied, and the lighter the sleep the more easily 
is it accomplished — they are the widest at the moment of awaking. 

The soundness of sleep may be determined by the intensity of 
the sound required to awaken a person. Some observers find that 
at first sleep deepens very quickly, then more slowly, and the 
maximum is reached after one hour ; it then rapidly lightens, until 
several hours before waking it is very light. We therefore sleep 



ANATOMY, THYSIOLOGY, AND CHEMISTRY 43 

soundest the first two hours, and weakest towards morning. The 
deeper the sleep the longer it lasts. 

The cause of sleep is the using up of the potential energy, 
especially in the central nervous system, which renders a restitu- 
tion of energy necessary. Perhaps the accumulation of the decam- 
position products of the nervous activity may also act as a sleep- 
producer. Sleep cannot be kept up for above a certain time, nor 
can it be interrupted voluntarily. Many narcotics rapidly pro- 
duce sleep. Hypnotics, such as opium, morphine, potassium bro- 
mide, and chloral, are drugs which induce sleep. 

Strength and Liminal Intensity of Stimuli. — Homologous stim- 
uli act upon the sensory organs only within certain limits as to 
strength. Very feeble stimuli at first produce no effect. The 
strength of stimulus which is just sufficient to cause the first trace 
of sensation is called by Fechner the " liminal intensity " of the 
sensation. As the strength of the stimulus increases, so also do the 
sensations, but the sensations equally increase when the strength 
of the stimulus increases in relative proportions. Thus, we have 
the same sensation of equal increase of light when, instead of 10 
-candles 11, or instead of 100 candles 110 are lighted — the pro- 
portion of increase in both cases is equal to one-tenth. As the 
logarithm of the numbers increases in an equal degree when the 
numbers increase in the same relative proportion, the law may be 
expressed thus : " The sensations do not increase with the absolute 
strength of the stimuli, but nearly as the logarithm of the strength 
of the stimulus.^' This is Fechner's " psycho-physical law,'' but 
its accuracy has lately been challenged by Hering. It holds good 
only with regard to stimuli of medium strength. If the specific 
stimulus be too intense, it gives rise to peculiar painful sensations 
— e. g., a feeling of blindness or deafness, as the case may be. 
The sense organs respond to adequate stimuli, but only with cer- 
tain limits of the stimulus — e. g., the ear responds only to vibra- 
ting bodies, emitting a certain range of vibrations per second; 
the retina responds only to vibrations of the ether between red 
and violet, but not to the so-called heat vibrations or to the 
chemically active vibrations. It was Weber who worked out the 
relation between the intensity of stimuli and the changes in the 
quantity of the resulting sensations. He used the method of 
" least observable differences," as applied to sensations of pressure 
and the measurements of lines by the eye. Hence it is called 



CORTEX 




SENSORY BRANCH 
TO MOTOR CELL 
IN ANTERIOR 
HORN. 



Each cell of the ganglia of 
the posterior roots of the spi- 
nal cord <or of the cranial 
nerve nuclei) gives off two. 
main processes. One, the den- 
drite, goes to the sensory end 
organ in the skin or elsewhere, 
bringing impressions to the 
cell, and constituting the pe- 
ripheral sensory nerve-fibre; 
the other, the axone, enters 
the cord through the poste- 
rior root ( or runs from the cra- 
nial nerve nuclei inward ), com- 
ing into relation with other 
neurones. 



BLOE"= DIRECT SETvlSORV PAThV/KV. 
RED = INDIRECT SENSORY PATHWAY. 



■ DENDRITES, 



Pig. 7.— Sensory Pathways. The direct sensor ij path (in blue) (for touch, pain, and 
temperature) runs from posterior root across the cord to antero-lateral cokimn, to 
tegmentum of crus, to optic thalamus, to cortex. _ The indirect sensory paths (in 
red) (for co-ordinative sensations from muscles, joints, and viscera) run upward on 
same side, via the direct cerebellar tract and the posterior column, decussating at 
upper part of cord, to cerebellum, to optic thalamus, to cortex. (From Butler.) 

44 



HORIZONTAL SECTION 

OF THE LEFT 

INTERNAL 

CAPSULE. 



VERTICAL SECTION 
OF INTERNAL 
CAPSULE. 



HORIZONTAL SEC- 
TION OF CRUS. 




CEREBELLUM AND 

INDIRECT MOTOR 

PATHWAY. 



MOTOR DECUSSATION 
IN MEDULLA. 



HORIZONTAL 

SECTION OF 

THE SPINAL 

CORD. 



DIRECT PYRAM- 
IDAL TRACT. 



ANTERIOR ROOT 
OF SPINAL 
NERVE. 



ANTERIOR ROOT 

OF SPINAL 

NERVE. 

BLACK FIBRES = INDIRECT PATHWAY. 
BLUE= PERIPHERAL {LOW£^', NE^AO:'.^ 

RED = CE'NTRAL fUPPER) NEURONE 
Fig 8.— Motor Pathways. Direct motor path (in red) (for voluntary impulses, 
runs from cortex, via corona radiata, internal capsule, crus, pons, medulla, crossed 
and direct pyramidal columns, to motor cells of anterior horn ; the cranial nerve 
motor fibres (in red) cross at various levels in crus, pons, and medulla. Indirect 
motor path (in black) (for musculr. co-ordination and higher reflex and automatic 
movements) runs from cortex to pons nuclei, to cerebellum, to lateral fundamental 
column, via the peduncles, the fibres terminating at various levels in the anterior 
horn. (From Butler.) 

45 



46 TREATISE OX XERVOUS DISEASES 

Weber's law; but Feehner expanded it, and assumed that all just 
observable differences are equally great, and so the law is some- 
times called by his name. Generally speaking, it is called Weher- 
Fecliners law. 

After-Sensations. — The term "after-sensation" is applied to 
the following phenomenon : viz., that, as a rule, the sensation lasts 
longer than the stimulus producing it; thus there is an after- 
sensation after pressure is applied to the skin. Subjective sensa- 
tions occur when stimuli due to internal somatic causes excite the 
nervous apparatus of the sense organ. The highest degrees of 
these, depending mostly upon pathological stimulation of the sen- 
sory cortical centres, are characterized as liaUucinations — e. g., 
when a delirious person imagines he sees figures or hears sounds 
which have no objective reality. In opposition to this condition, 
the term illusion is applied to modifications by the sensorium of 
sensations actually caused by external objects — e. g., when the 
rolling of a wagon is mistaken for thunder, etc. In other words, 
an illusion is the misinterpretation of an objective stimulation. 

Ideation is the formation of ideas caused by cerebral activity. 

The Sympathetic Nervous System: Function, Etc. — It consists 
of a double chain of ganglia on each side of the spinal column and 
visceral plexuses. It is chiefly composed of non-meduUated nerve- 
fibres. Its chief function is vaso-motor. Its ganglia are readily 
paralyzed by nicotine. 

OTHER NON-NERVOUS TISSUES 

Blood-Vessels. — The nerves are richly supplied with blood. 
The peripheral nerves also are supplied from different arterial 
branches, but always from one general source. The artery passes 
to the nerve-sheath obliquely, then divides dichotomously, send- 
ing branches for a long distance uy and down the sheath. It 
may pierce the sheath first, however, then divide as above de- 
scribed. The dichotomous branches send off arterioles and capil- 
laries which form plexuses about the nerve fascicles, the so- 
called " interfascicular arcades." This division of the arteries 
subserves the function of preventing large and sudden impact of 
blood into the parenchyma of the nerves. This resembles also 
the brain and cord distribution of the blood. 

The veins subdivide dichotomously like the arteries, and freely 



AX ATOMY, riiY^SlOLOGY, AXD CHEMISTRY 47 

anastomose with the veins of the muscles, so that muscular action 
is in close sympathy with nerve function and circulation. Veins 
of superficial nerves thus also connect with the deep nerve veins. 

Lymphatic vessels and spaces are found in the epineurium and 
perineurium. There are no demonstrable lymphatic vessels in the 
fasciculi of nerves, but lymph spaces probably exist. 

Neuroglia. — In addition to connective tissue, the central nerv- 
ous system has another substance not found in the peripheral 




Fig. 9. — Showing the relation of the spinal cord to the dorsal surface of the trank 
the relative length of the cervical, dorsal, lumbar, and sacral portions ; and the 
position of the cervical and lumbar enlargements. 



nervous system. It is called the" neuroglia and is derived from 
the epiblast. Its cells are very numerous and are finely ramified 
together, in the which they support the nerve-cells. They are also 
called " spider cells " and consist of a large nucleus and proc- 
esses. 

Sectiox III. — Chemistry 

Neuroglia. — One point in the chemistry of the neuroglia 
should preface this section — i. e., the processes of these cells be- 



48 



TREATISE ON NEIU^OUS DISEASES 



come charged in their chemical and physical characters so that 
they take on different stain from that of the cell body itself 
(Weigert). The scavenger cells of Lewis are the nenrogliar cells 
produced by inflammatory irritation which carry off irritating 
products; and this must be some form of chemical combination as 
yet awaiting the physiological chemist to solve. 

Nervous Tissue. — According to Krause and Bischoff, the spe- 
cific gravity of nervous tissue is 1.036; that of the brain 1.038, 
of the spinal cord and nerves 1.034„ The reaction is alkaline 
owing chiefly to the production of lactic acid. 

Water makes up three-fourths of nervous tissue. There is 
more water in the gray than in the white matter, and least water 
in the sympathetic nerves. Inorganic salts are about 5 per cent 
of -the total constituents of nerve-tissue. According to Breed, 
phosphorus is the largest single element, and it is combined with 
calcium, magnesium, sodium, potassium, and iron-forming phos- 
phate salts. Chloride of potassium is the most important of the 
other constituents. 

Table of Chemical Constituents of Nervous System 
(Baumstark — quoted by Hammerstein and by Dana) 



• 


White matter. 


Gray matter. 


Water in 1,000 parts 


603.35 
304.65 

25.11 

50.02 
45.12 

2.94 
18.93 

5.23 


769.97 


Solids '' " " 


230.03 


Protaffon 1 f^^'S':''', • ^l • • 


10 08 


jrroidgoii -j igcithm (neurm) / 

Insoluble albumin and connective tissue. . . . 
Cholesterin 


60.79 
23.81 


Nuclein 


1.99 


Neurokeratin 

Inorsranic salts . . . . 


10.43 
5 62 







Protagon is a complex substance of _atty matter containing 
nitrogen, united with glycerin-phosphoric acid instead of glyc- 
erin. This protagon is made up of two bodies, cerehrin and leci- 
thin, the latter of which contains an ammonia compound called 
neurin. Protagon is especially abundant in the white matter. 
The gray matter contains nuclein, important in cell metabolism. 
Nuclein (CsgH^gNgPgOga Miescher) consists of nucleic acid, a sub- 
stance rich in phosphorus and a various amount of albumin. The 
Qerve-cells (gray matter) also contain various amounts of albumi- 



ANATOMY, PHYSIOLOGY, AND CHEMISTRY 49 

nous substances. According to Halliburton, ni^c/em and its con- 
gener nucleo-alhumin are designated albuminoids. They both con- 
tain albumin and are found chiefly in the nucleus. The albu- 
minous substances are also called proteids and contain little or no 
phosphorus and make up most of the cytoplasm or cell body. 



CHAPTEE II 
GENERAL PATHOLOGY 

The nervous system, composed as it is of nerve-cells and 
fibres forming the neurones, the connective tissue, the neuroglia, 
blood-vessels, and lymphatics, must have in its pathology disease 
of one or many of these structures. Most diseases affect the 
blood-vessels, connective tissue, or neuroglia primarily, and paren- 
chyma secondarily, although in many affections it still remains 
doubtful which is first diseased. 

Forms of disease which affect the nervous system are, there- 
fore, as follows: 

1. Functional and nutritive disorders, including those of meta- 
bolic and glandular defects as in exophthalmic goitre, cretinism, 
or myxoedema and acromegaly. 

2. Malformations, lack of proper development or agenesis; de- 
fective development or dysgenesis. 

3. Anaemia, hemorrhage, and arterio-venous disease. 

4. Atrophy, degeneration, softening, gliosis, and sclerosis. 

5. Hypergemia, oedema, and inflammations. 

6. Tumours, parasites (echinococcus, etc.). 

7. Syphilis, tuberculosis. 

Under nutritive and functional disorders of the nervous system 
come defects in metabolism, as uric-acid diathesis causative of a 
certain number of cases of neurasthenia; also under this comes, 
as just mentioned, other autochthonous poisons such as leuco- 
maines. Then come the extrinsic poisons, as ptomaines developed 
from intestinal intoxication, etc. 

Sclerosis is a process of connective-tissue proliferation in which 
the normal parenchymatous tissue is supplanted by connective tis- 
sue. This is the result of degeneration (next to be considered). 
Neuroglia overgrowth also usually occurs in sclerosis. 

Degenerations may be divided as follows, into acute and 
chronic, and these again are subdivided into primary and secondary 
50 



GENERAL PATHOLOGY 51 

and mixed. Under primary come the progressive muscular atro- 
phies of spinal origin, myelomalacia and tabes dorsalis, or an}' of 
the system diseases of the cord. Under secondary degenerations, 
we may give as examples secondary lateral sclerosis as in that fol- 
lowing upon hemiplegia of cerebral origin or in degeneration 
(diffuse) of the cord following chronic myelitis or syringomyelia. 
Acute degeneration usually brings about a softening or necrosis. 
If repair occurs a cicatrix is formed. 

Primary degenerations are, of course, due to inherent defect 
in nutrition or to some poison (as that of syphilis in the fourth 
stage) acting directly on the fibre or cell. Secondary degenera- 
tion is per coritra due to separation of the nerve-fibre or cell from 
its trophic centre, or to cutting off of its vascular supply, or to 
injury as in pressure neuritis, etc. 

The most usual extrinsic poisons that cause degenerations are 
arsenic, lead, phosphorus, or the poisons of infectious diseases 
as of la grippe. Endarteritis and arteriosclerosis of old age 
also cause degenerations by obliterating the lumen of vessels, 
and thus preventing proper nutrition of the part beyond. There 
is a legion of causes which with all our scientific advancement are 
as yet unknown, but are productive of premature death of the cell. 
Whether certain scleroses are forms of proliferative inflammation 
is as yet also a debated question by pathologists, although the tend- 
ency is now to term the so-styled chronic inflammations as really 
degenerative processes, and that, as indicated above, the primary 
trouble is in the parenchyma. 

Gliosis. — Dejerine is the leader of the French school who be- 
lieves that some of the chronic degenerative diseases are due to 
proliferation of neuroglia. This overgrowth of neurogiiar tissue 
rather than connective tissue is termed gliosis. 

Inflammations. — Since the pathology of most of the types of 
disease above outlined are given under their respective heads, we 
shall dwell upon the main pathologic changes only in this chapter. 

Inflammation should be understood as to its nature, as the 
student should also have a clear comprehension of degeneration of 
nerve-tissue. Inflammation has primarily to do with blood-vessels, 
then lymphatics, and finally formation of connective tissue. It is 
the reaction of an organism to an irritant, so that wherever there 
is inflammation there has been irritation. Products of growths of 
micro-organisms, or some irritant the product of tissue change, are 



62 TBEATISE OS XEBTOITS DISEASES 

usually the immediate causes of the irritation. But certain chem- 
ical substances, as alcohol, lead, or arsenic, as previously men- 
tioned in this section, may produce inflammations directly; al- 
though they are more apt to be causative of primary or degener- 
ative (destructive) processes. 

When the irritant is removed, inflammation tends to subside — 
i. e., it is then regressire not a progressive process. 

Inflammations are further diyided into — 

1. Productiye forms (Delafield). 

2. Exudative forms — ^these forms may be simple ioflanunations, 
without necrosis or with necrosis, purulent or purulent and ne- 
crotic. 

Produdive or proliferative inflammation is a process in which 
there is little congestion and exudation, but new connective tissue 
sltmrly forms. It is usually chronic. Examples of this form are 
syphilitic or tubercular iDflammations (producing specific ^anu- 
lomata or tubercles). Lead, alcohol, arsenic may also produce this 
form, as may the poisons of rheumatism, gout, diabetes^ states of 
inanition (/?se!i<fo-palsies of rickets, etc.). 

Exudative inflammation is associated with first a congestion, 
then stasis, exudation of white blood corpuscles (amoeboid move- 
ment), diapedesis of the red blood cells, transudation of blood 
serum, the final formation of fibrin; the complete result being an 
exudate containing white blood cells, now called pus cells, and 
fibrin. In some instances there is no destruction of tissue in this 
form of inflammation, and after its subsidence the tissues affected 
return to the normal state. In other cases the nerve tissue is 
partly destroyed. In the puntUnt form there is great increase of 
pus cells and but little fibrin. If the tissue is also destroyed it is 
a purulent and necrotic form of inflammation. In some forms of 
exudatiye inflammation increase of connective tissue takes place 
from the outset, and this latter continues until the inflammation 
subsides. Most forms of this exudative type are acute or subacute. 
Inflammatory cedema, so called, is of this type of inflammation. 

Xerve-c-ells proper once destroyed never re-develop. This is 
not true of nerve-fibres, and while these frequently develop again, 
they but seldom do so within the tracts of the central nervous sys- 
tem. The peripheral nerves when regenerating always grow from 
their trophic centre. Xerve-tissue in hram, cord, or nerve will not 
reunite, after section, by direct union. With but very few excep- 



GEXERAL PATHOLOGY 53 

tions there is a primary degeneration of the cut ends, which is then 
followed by regeneration. Xerrous tissue is further dependent 
upon its blood supply and its trophic connection for its vitality. 
The nerve-cell is absolutely dependent on the blood supply, while 
the neuraxone is dependent upon the trophic influence of its con- 
necting cell, though it can survive for a time the simple exclusion 
of its blood supply. If the neuraxone is injured it affects the cell, 
which can be repaired, however. 

Tumours will be described under the heading of Xeoplasms. 



CHAPTER III 
GENERAL SYMPTOMS AND METHODS OF EXAMINATION 

NOMENCLATURE IN NERVOUS DISEASES 

Neurosis applies to a functional condition of the nervous S3''s- 
tem^ wherein the higher centres (of the mind) are not involved, 
such as in neurasthenia. 

Where the higher faculties of mind are involved the name psy- 
chosis is given, as in h3^steria or insanity. 

Stupor is that state of unconsciousness in which the patient 
can be partiall}' or completely aroused; and in which the reflexes 
are preserved. 

Coma is that state of unconsciousness from which the patient 
cannot be aroused and wherein the reflexes are absent. 

Hypercesthesia is a term used to indicate increased s^ensibility. 

Hypcesthesia applies to decrease of sensation. 

Par(Bstliesia is a perversion of common sensation, such as ting- 
ling, numbness, or formication, which latter is a sensation as 
though ants were crawling over the body. 

Spasm or convulsion is a symptom in which there is violent 
contraction of the muscles, and may be localized or general. Fre- 
quently spasm is used in the sense of a localized convulsion alone, 
although this is not technically correct, and local spasm is prop- 
erly called '' tic," ^ such as " tic "^ of the face — a spasm of the 
seventh nerve. Convulsions are further divided into clonic and 
ionic. In the former the movements are in rapid succession, and 
in the latter the contraction is maintained for a long period of 
time. Hysterical convulsions are particularly apt to be of a tonic 
nature. (See illustration, p. 56.) 

There are certain definite affections of different tracts of the 
central nervous system which are given special prominence in the 

» Tic may also apply to a painful paroxysm in neurological nomenclature; 
but then the ^x^fm painful is used in explanation, or an affix as in ''tic doulou- 
reux. " 

54 



GUIDE TO NOTE-TAKING 

INFIRMARY FOR NERVOUS DISEASE, PHILADELPHIA 

No. of Case. Name of Book. Date. Service of Doctor. 
Name. Eesidence. Age. Sex. Eace. 
General Statement to Aid in Classifying Case. 
Family History: 

Hereditary Tendencies — Health of Parents — Syphilis— Gout — Diabetes, 

etc. 

Personal History: 

Married or Single — Children — Relation of Work to Present Trouble — . 
Illnesses — Inj uries — Syphilis — Nervous Diseases — Habits — Tempera- 
ment — Life, Active or Sedentary — Occupation — Exposure to Poisons — 
Malaria — Lead — Tobacco — Alcohol — Narcotics — Opium, etc, — Usual 
Weight— Height. 

Date of Onset of Present Trouble : 

Supposed Cause — Mode of Onset and Outline of Course. 

General Aspect: 

Weight now — Colour — Skin — Hair — Eyes — Scars on Head, etc. 

State of Organs: 

Present — Comparing Past. 

1. Digestion: 

Tongue — Bowels — Appetite — Rectum — Teeth — Liver — Spleen— Taste. 

2. Respiration: 

L ungs — Throat — Nose — S m ell. 

3. Circulation: 

Heart — Pulse — Arterial Tension — Blood — CEdema. 

4. Uro-Genitory : 

Catamenia — Leucorrhoea — Displacements — Phimosis Scars — Sexual 
Functions — Pow'er, etc. — Urinalysis — Colour — Sp. Gr. — Albumen — 
Sugar — Uric Acid^Oxalates — Urates. 

5. Nervous System : 

(a) Motility — Voluntary Movements — Strength — Grasp — Co-ordination 
— Spasms — Reflex Capacity— Knee- Jerk — Arm- Jerk — Jaw- Jerk — Skin — 
Cremaster, etc. — Muscle- Jerks — Clonus — Station — Sway — Bladder Con- 
trol. 

(&)* Sensibility — Subjective Sensations — Hyperaesthesia — Anaesthesia, etc. 
— To contact (^sthesiometer), to pain, to temperature — Intellectual 
Functions — Hallucinations — Delusions — State of Will — Predominant 
Ideas — Specify Insane Acts — Sleep — Vertigo — Tenderness over Nerves — 
Headaches — Electrical Examination — Trophic Alterations — Vaso-motor 
Activities. 

6. Sight: 

Vision (Type — Fingers — Colours) — Field — Fundus — Ocular Muscles 
— Pupils. 

7. Hearing: 

Deafness — Wax — Tinnitus. 

55 



56 



TREATISE OX XERYOUS DISEASES 



study of diseases of the nervous system, and lead to assist in the 
diagnosis through knowing the results of anatomical or physiolog- 
ical perversions in them. In the sensory tracts we have mani- 
fested pain^ dull or shooting in character; parcesthesia, or numb- 
ness of a part; causalgia, or burning pain, frequently occurring 
in peripheral neuritis — all due to irritative lesions of these tracts. 
A diminution of the function of the sensory tracts will produce 

hypaesthesia. anaesthesia. 
Different distributions of 
anaesthesia are of nerve- 
trunh, the circumscribed, 
the segmental or glove-like 
— where the anaesthesia ex- 
tends up an entire extrem- 
ity, such as from the finger- 
tips to the elbow, as in 
cases of hysteria. Hemian- 
(estliesiu,, is a condition 
where half of the body is in- 
volved— ;this being of two 
different kinds — organic 
and functional, a point of 
difference being that func- 
tional or hysterical anaes- 
^^^^^ ^ thesia, so called, has a dis- 

^^^HB^^ tinct dividing line in the 

^^^^^■^^P median line of the body — 
I mmM whereas organic hemianaes- 

■ -«■■. thesia will extend slightly 

beyond the median line, due 
to the distal crossing of 
nerve-fibres beyond the median line ; or, better, this latter is anaes- 
thesia from the centre to the ultimate end of the nerve-twigs. The 
destructive lesion of the spinal cord involving one-half of it will 
produce symptoms of complete hemianaesthesia and slight motor 
loss below the site of lesion on the opposite side, with complete 
motor loss on the side of lesion. Usually it is only pain 
and temperature sense that are lost, since the lesion is, as a rule, 
limited. This is called Brown-Sequard paralysis, named for 
him who first described it, and is due to the fact that the sen- 




FiG. 10. 



-rosiTiox OF Hand in Local Tonic 
Hysterical Spasm 



SYMPTOMS AXD METHODS OF EXAMIXATIOX 57 

sory fibres upon entering the cord cross to the opposite side, then 
pass Tip. 

In pontine lesions we may have a hemianaesthesia of same side 
of the face with motor and sensory palsy on the opposite side of 
the body to the lesion. 

Algesia refers to the pain produced in a part either by external 
or subjective stimulation of sensory nerve-fibres or neurones. 

Muscle sense is that phenomenon by which we distinguish space, 
shape, size ; also the location of parts of the body. 

Asteriognosis refers to the inability to appreciate dimensions, 
density, and shapes of objects. 




11.— Keauss's Plessimetek, 

By tmscrewing the caps C and D it maybe used as an aesthesiometer, 
or as a brnsh for testing tactile sensibility. 



Temperature sense is the faculty of appreciating temperatures 
of bodies^ such as heat and cold. 

Reflexes are phenomena produced by irritation or by stimu- 
lants of some sort either from within or from without. Ordinarily, 
the reflex consists of an afferent impulse, which is carried over 
the sensory tract to the nerve-centre in the cord or brain. The 
impulse is then transmitted to the centre, which consists of a 
collection of nerve-cells within the cord or brain; and finally the 
efferent impulse completing the reflex is carried over the motor 
tract or fibres from the nerve-centre, producing motion, secretion, 
and various physiological phenomena of the body, depending upon 
the nature of the reflex action. 

Eeflexes are divided into superficial and deep and visceral. 
Superficial are those occurring upon the surface of the body, such 
as skin and mucous membranes. We have among them the pupil- 
lary sTcin reflex, which consists of a dilatation of a pupil, produced 
by the irritation of the skin of the neck, as in pinching the same, 
the impulse being carried up by the cervical sensory nerves, and 
down as a motor impulse through the motor s^Tupathetic nerve- 
fibres to the dilator muscles of the pupil. The pectoral reflex con- 



58 



TEEATISE ON NEEVOUS DISEASES 



sists in contraction of the pectoral muscles through the skin over 
them. The epigastric reflex consists in a contraction in the epi- 
gastric region through the fibres of the recti muscles. The abdom- 
inal reflex consists of contraction of the abdominal mnscles when 
the abdomen is irritated. The supra-orbital reflex of McCarthy 
consists in elevation of the lower lid when the supra-orbital region 
is gently tapped. There are a nnmber of others not of practical 
importance to the student. 




Fig. 12. — Showing the Jendrassik Method of Obtaining the Knee-Jerk. 



The cremasteric reflex consists in retraction of the testicle 
when the skin of thigh is irritated. 

The plantar reflex consists of flexion of the toes when sole of 
the foot is irritated. 

The palmar reflex consists in jerking of hand and closing of 
the fingers upon irritating the skin. 

The infra-orbital reflex consists of the elevation of the lower 
eyelid when the supra-orbital region is irritated by a blow. 



SYMPTOMS A^D METHODS OF EXAMIXATIOX 59 

Deep reflexes or muscle reflexes are produced by tapping a muscle 
or tendon and causing contraction of the muscle. The knee-jerk 
is produced bv tapping the ligamentum patella, the leg being 
loosely pendant at right angles to the thigh. There is extension 
of the leg. 

The tcndo-Achilles reflex is produced by tapping the tendo- 
Achilles, when extension of the foot will occur, due to the con- 
traction of the gastrocnemius group of muscles. 

The conira-laieral or adductor femoris reflex is one pro- 
duced by tapping the ligamentum patella on one side, the patient 
sitting on the edge of a chair with both limbs loosely resting on 
the feet. If this reflex is present adduction of the opposite thigh 
will occur. This is an inconstant reflex, and although it cannot 
be said to be pathological in significance, it is much increased in 
cases of spastic disease, as a rule, especially when involving the 
lateral columns of the cord. 

Anlde clonus is a deep reflex, always pathological, and is 
produced by sudden flexion of the ankle, the physician support- 




er 

Fig. 13 —Taylor Knee-Jerk Hammer. 

ing the calf with one hand and firmly pressing on the sole or 
ball of the foot quickly. If present there v.ill be a to-and-fro 
clonic involvement of the foot due to contraction of the soleus ^ 
and gastro-intestinal muscle. This is called true ankle clonus. 

A psuedo-anl'le clonus is that inconstant clonic contraction of 
the same muscle group, occurring in neurasthenia or hysteria. It 
is also called abortive ankle clonus, since it is soon exhausted. It 
does not signify organic disease of the cord, as the true form 
always doe^-, 

The elhoiv-jerl' consists in tlie extension of the elbow, produced 
by tapping the tendon of the triceps muscle when the arm is held 
pendant over the table or other object. 

1 Weir-MitcheU beheves it is entirely due to action of the soleus. 



60 



TREATISE ON NERVOUS DISEASES 



The hiceps-jerk consists in flexion of the elbow, when the biceps 
tendon or muscle is suddenly tapped. 

The extensor reflex of the wrist consists of the extension at the 
wrist when the extensor group of mnscles are tapped. 

The wrist reflex proper consists in flexion when the flexor mus- 
cles are tapped. 




Fig. 14.— Showing Method of Obtaining the Triceps and Supinator Jerk. 



The jaw-jerk consists in sudden closing of the mouth when 
tapping over the mental process of the inferior maxilla. 

Paradoxical contraction consists of a tonic contraction of the 
anterior tibial m.uscles, produced by a sudden flexion of the foot 
or the leg. This sudden shortening of the muscles indicated 
causes the tonic spasm which is always pathological. 

Superficial and deep reflexes are said to be increased when there 



SYMPTOMS AXD METHODS OF EXAMIXATIOX Gl 

is a decided increase of the movement over the normal; lessened 
when there is a lessening of the normal amount of movement upon 
its development. Of course reflexes are absent where no response 
occurs. The two extremes of reflex action are spastic where the 
reflexes are greatly increased, and ahsent when there is no reflex 
at all produced on external stimulation. Several other terms are 
used in describing reflexes, such as moderately increased and 
greatly increased, and related to the spastic as described. Also 
the other extreme — slightly diminished and greatly diminished. 
exists before abolition of the reflexes occurs. 

Visceral reflexes is the third group, and consists of the ac- 
tion of the various viscera, etc., induced by irritative phenom- 
ena; as the peristaltic movements of the stomach, after taking 
of food. 

The Eye. — The liglit reflex is produced by throwing a bright 
light into the eye, causing contraction of the pupil. Accommoda- 
tion reflex is brought out by causing the subject to look at a near 
object when the pupil also suddenly contracts. When the light 
reflex is lost and accommodation is still present the Argyll-Eobert- 
son pupil is said to exist. 

Eeflexes of the bladder, rectum, and sexual apparatus are also 
important; the two former being under control of the higher 
centres. If the tone of the compressor urethras is intact, the reflex 
being lost, we have incontinence of overflow as a sign. 

Damage to the genital reflex arc causes loss of erection and 
sexual desire. Loss of inhibition may cause priapism. 

TROPHIC, VASO-MOTOR AND SECRETORY 

PHENOMENA 

By trophic disturbances we refer to certain conditions, as the 
wasting of muscles, false hypertrophy of muscles, bedsores, joint 
disease, trophic changes in same, such as the arthropathies, brittle- 
ness of the nails, hypertrophy of bone, such as in Pagef s disease, 
where the cranial bones are enlarged. 

Vaso-motor disturhances refer to the conditions dependent 
upon disease of the nervous system, as flushing, oedema, angeio- 
neurotic oedema, coldness and clamminess of the extremities. 

Secretory phenomena and disturbances thereof, consists of, 
among others, retention, or too much elimination of certain secre- 
tions; in the former in the case of the thyreoid gland, we have 



62 



TREATISE ON NERVOUS DISEASES 



developed a disease to be studied in another chapter — cretinism 
and myxoedema. Excess of thyreoid secretion probably occurs in 
exophthalmic goitre. 



EXAMINATION OF THE 
PATIENT 

Examination of the patient for 
nervous disease includes a study the 
most thorough in general medicine, in 
order to exclude other maladies; and 
specifically, of course, for the deter- 
mination of the status of the nervous 
system. It will be in keeping with the 
book to pass by intricate medical meth- 
ods, therefore, insisting upon their im- 
portance, however, and to hasten on to 
the examination of the nervous system 
itself. 

Gait and Station. — Station is the 
attitude, the manner of holding the Fig. 15 
body in the upright posture, the feet 
being in the position of " atten- 
tion.'' The station is said to be normal when the patient but 
slightly deviates from the erect posture while standing, the 
sway tending towards no particular direction. The station is 
said to be ahnonnal when the patient does sway markedly. 

In designating this symp- 
tom, right, left, forward or 
backward are used to indi- 
cate the direction of the 
abnormal deviating move- 
ment. An unsteady sta- 
tion is called Roml)erg's 
sign, particularly found in 
tabes. 
The sway should also be tested with the eyes open and with the 
eyes closed, since it will always be found more perverted when the 
eyes are shut, especially in diseases where muscular sense is much 
disturbed, as in tabes, referred to above. 



Weir Mitchell's 

APPARA.TUS FOR CLINICAL OB- 
SERVATIONS OF Station. 




Fig. 16.— Foot Dynamometer. 



SYMPTOMS AND METHODS OF EXAMINATfON 63 

Gait is the manner of progression of the individual. It is 
to be noted that there is a difference between the normal gaits of 
the two sexes. The female, due to the breadth of the hips, has a 
more or less waddling progression, whereas the male movement is 
more directly forward in walking. 

Patients should not deviate from the direct line of progression 
in any one direction more than another, although a natural sway 
does occur, and there are particular family types of normal pro- 
gression. 

Grasp is determined by the dynamometer. It is of use to 
compare palsy of the hand and forearm muscles. 

PATHOLOGIC GAITS 

1. Hemiplegic, or that type in which the individual carries one 
side of the body forward with the muscular action of the unaf- 
fected side, plus gravity. The patient brings the affected leg 




Fig. 17.— Hand Dynamometer. 

forward in flail-like fashion, using the opposite foot as a pivot, 
the toe of the affected side dropping to the ground before the 
step is completed, so that a tracing of this gait will present a 
short stride of the affected side, followed by the longer stride of 
the healthy limb. 

2. Spastic is one characterized by the forcing of the toes down- 
ward in flexion during progression. In its incipiency the wearing 
out of the toe of the shoe may be the most prominent sign. Later 
the ball of the foot is '' dug " into the floor, the patient stumbling 
over the slightest impediment. The knee-jerk is found to be in- 



64 TREATISE OIST NERVOUS DISEASES 

creased, though it may be difficult to elicit on account of flexor 
contractions. 

3. Ataxic is one where the patient throws the limb outward, 
forward, and downward, the heel dropping first, and all the move- 
ments being inco-ordinate. This gait is decidedly worse when the 
patient is in the dark or when closing his eyes. The knee-jerk is 
usually absent. It is increased in ataxic-paraplegia. 

4. Titubation is characterized by a rather sudden deviation 
to right or left during progression. As a rule, the patient 
" catches ^' himself before more than one or two steps away from 
the normal are made. This gait is rather characteristic of the 
inco-ordination produced by cerebellar disease where centres for 
balance lie. 

5. Steppage gait is that in which the patient lifts the toes 
high from the surface, such as normally is done in ascending 
stairs. The cause for this exaggeration lies in the fact that there 
is palsy of the anterior muscles of the leg. This gait occurs in 
neuritis and the muscular dystrophies. It is almost pathogno- 
monic of these conditions. ' 

6. Festinating gait (or running gait). Here the patient tends 
to go forward rapidly, as in paralysis agitans, in which disease 
a sensation of falling forward (propulsion) or backward (retro- 
pulsion) may also occur. 

PHYSIOGNOMY 

• Physiognomy of the patient has much to do with the deter- 
mination of certain features of the nervous malady. Besides the 
final delineations of feature, showing depressive mental states or 
the opposite, a temperament is shown by irhe examination of the 
facies, of which the following are of some worth in studying the 
case — namely: 

Lymphatic temperament, in which the face, along with other 
structures, presents a pale and waxy sallow aspect, and in which 
the subcutaneous tissues are flabby and the skin is unduly wrinkled. 
Such persons are apt to be large of skeleton, out of proportion to 
the musculature, and their circulation is sluggish. 

Sanguineous temperament is characterized by the face present- 
ing a florid complexion. Prominence and tension of the sub- 
cutaneous tissues, with perhaps excessive development of fat 



SYMPTOMS AXD METHODS OF EXAMIXATIO]Sr 65 

cells, is seen; the neck usually appearing short and the chest 
broad, out of proportion to the general physique. It should be 
stated that this type is predisposed to apoplexy among nervous 
diseases. 

Bilious temperament is, typically, found in those ^\'ith dark 
hair and complexion. The salient features are tendency to jaun- 
dice, to a melancholy physiognoni}-, the tongue being usually 
coated and bowels constipated. Such types are likely subject to 
nervous depressive diseases, such as hypochondriasis and melan- 
cholia, or to the neurasthenias dependent upon gastro-intestinal 
auto-intoxication in some measure. 

Nervous Temperament. — Here the individual expression is one 
of vivacity, eyes are alert, movements quick; vrith a musculature 
that is not large, but the muscles are distinctly outlined, as in the 
thoroughbred, the bellies being prominent. These people are most 
likely to come under the list of nervous patients, because they do 
the world's work. 

Neuro-Bilious Temperament. — This is a type we can well des- 
ignate in America, since our methods of life conduce to modifica- 
tion of the other temperaments towards the nervous ; and since the 
bilious temperament, as indicated, is not itself an important factor 
in nervous disease, but when added to by the nervous element 
there is reason to make the above designation. This type is the 
most difficult to manage in any case of nervous or mental disease. 

DECUBITUS 

In neurology the position of the patient, as he lies in bed, is 
important to note in making an examination. 

In decubitus of meningitis, as a rule, the patient lies supine, or 
on his side, with retraction of the head and hyperextension of the 
back, plus general muscular rigidity. 

In hemiplegia the patient usually lies upon the back, the one 
side of the body being assisted by the normal extremities. 

In tetanus and hydrophobia the decubitus is not consistent, 
but is somewhat like that of meningitis, the patient more frequent- 
ly remaining on the side, however. Tonic and clonic convulsions 
occur spontaneously or with the slightest reflex excitement. In 
both of these diseases there is frothing at the moiitli. 

Decubitus of an epileptic attack consists of the patient lying on 



66 



TEEATISE OX NERVOUS DISEASES 



the back usually in the typical convulsion, with conjugate devia- 
tion of the eyes and dilated pupils. Following the attack the 
patient remains limp, supine. He may, of course, fall upon his 
face in exceptional instances. 

Decubitus of neuritis is not constant, depending upon the 
degree and extent of nervous inflammation and palsy. The pa- 
tient always tends to protect the extremity or part affected, and 
this will extend to the guarding of the extremity from any injury 
or contact, as of the bed-clothing, when there is active neuritis. 



EXAMINATION FOR SENSATION 

This is done by means of the aesthesiometer, to determine the 
presence, absence (anaesthesia), or diminution (hypaesthesia), or 
exaggeration (hypersesthesia) of common sensations. Dysaesthesia 
is an abnormal sensation, such as a feeling of discomfort pro- 
duced by ordinary tactile or painful impres- 
sion. Paraesthesia is a subjective sensation, 
such as a feeling of pins and needles prick- 
ing the affected part, and occurs frequently 
in early neuritis, as in pressure palsy. 

Causal gia is a " burning " sensation 
found in some cases of neuritis of chronic 
type, as in erythromelalgia. 

Formication is the sensation as of ants 
crawling over the surface of the skin; often 
a delusion of mental disease. 

For the finest determination of sense of 
touch, a piece of cotton twirled at the end 
will be found efficacious; or better the aes- 
thesiometer. In testing, it should always be 
done symmetrically, since one person may 
differ from another, according to the tem- 
perament, so that a standard cannot be set 
for all persons from one case. It should be 
remembered, too, that special parts of the body are more sensitive 
than others, such as the face and the lips, tongue, and palms of the 
hands and feet. 

To test the thermic sense, heat and cold are applied through 
water in test-tubes. The absence of thermic sense (thermo-anaes- 




FiG. 18.— Carroll's 

^STHESIOMETER. 



SYMPTOMS AXD METHODS OF EXAMIXATIO:^" 67 

thesia) is to be expected in cases of syringomyelia, where the 
touch sense may be retained in the absence of thermic sensation — 
the so-called disassociation of sensation. 

Algesia or pain sense is tested by means of a sharp instrument, 
as the ^sthesiometer. This, also, may be absent (analgesia) with 
preservation of the other fotms of sensation in some cases of hys- 
teria, etc. 

EXAMINATION FOR MOTION 

The motor phenomena are examined for, first, as to palsies. 
These can be tested by means of the hand or foot dynamometer, 
which is an instrument by which record is made on a dial of 
the amount of force used to compress the oval spring. In 
testing the strength of the lower extremity, the instrument is 
suspended from the shoulder, and by means of a strap, attached 
also to the dynamometer, the amount of pressure can be regis- 
tered. This should be used bilaterally, since the record is only 
for comparison. The palsy in other parts is noted by the strength 
shown in movement of the part of the muscles, as in effort to 
lift some object, etc. Individual muscle palsies are noted by obser- 
vation, the anatomical position of the part involved, and in rela- 
tion to the motor nerve supply, thus giving way to opposing 
normal muscles. 

The opposite of paralyses, convulsions, are determined by 
means of the sense of sight. 

A contraction is a shortening of the muscle of a part, which 
cannot be forcibly extended even under etherization of the patient. 

A contracture is the shortening of a muscle, which can be re- 
lieved by firm extension, the muscle therefore not being actually 
organically diseased. It may be necessary to etherize the patient 
to accurately test this. 

Paralysis may be partial or complete, the former scientifically 
being designated paresis. 

The forms of paralysis are: 

Hemiplegia, involving one-half of the body. 

Monoplegia, where the palsy is confined to one limb of the 
body. 

Paraplegia, where both the lower extremities are affected. 

Diaplegia, where the palsy involves corresponding extremities, 
as the two legs, two arms, or all four limbs. 



68 



TEEATISE OX NERVOUS DISEASES 



Loss of the special sensibility of the muscles^ articular sur- 
faces, and tendons produces ataxic movements. 

Ataxic movements are inco-ordinate movements, as in loco- 
motor ataxia; or in cerebellar disease or in neuritis. Apprecia- 
tion of weight and position of limbs are lost in ataxia. 

Static ataxia consists in loss of equilibrium when the patient 
or part is at rest. 

Cerebellar ataxia is produced by cerebellar disease. 

Motion of an unparalyzed limb or a limb that is partially 
paralyzed will occasionally produce movements in the correspond- 
ing paralyzed extremity. This is designated as associated move- 
ment. A forced movement is one produced in spite of the patient's 
will, as when the patient is suddenly whirled about in various 
directions. 

Some other abnormal movements are tremors, spasms, and 
choreiform convulsions. 

Tremors are fine, coarse, intentional, and continual. 

The following table gives the various causes of tremor and 
their character : 



Cause. 


Type of tremor. 


Rapidity. 




' Arsenic. 


Intention in early stages ; 


Rapid. 




Lead. 


later may become con- 




Toxic... ^ 


Alcohol. 


stant ; may then be in- 




Tobacco. 


creased by exertion. 






Tea. 








_ Coffee. 








' Hysteria. 


Ibid. 


That of hysteria some- 


Neuroses ^ 


Neurasthenia. 




times is slow; others 


Exophthalmic 




always rapid. 




Goitre. 






Senility 


Ibid. 


Rapid. 
Rapid. 
May be slow or rapid, or 


Heredity 


Ibid. 


Any disease of brain, 


Ibid. 


SjDinal cord, or periphe- 




both combined. 


ral nerves, excepting 




^ 


multiple sclerosis and 






paralysis agitans. 






Paralysis agitans 


Often ceases for a few 
seconds after muscular 
exertion. 


Slow. 


Multiple sclerosis 


Intention only. 


Slow. 



Spasms may be tonic or clonic, the latter consisting in rapid 
movements; but when the contraction persists it is designated 
tonic; when permanently persisting, it produces what is called 
muscular rigidity, as in the extremities, neck, or trunk. 



SYMPTOMS AND METHODS OF EXAMINATION 69 

Choreic movements are sudden, or jerking, irregular inco-ordi- 
nate movements. 

Convulsive tic is a form of choreic movement confined to cer- 
tain groups of muscles and limited to muscles physiologically 
grouped for certain functions, as the respiration, or expression, or 
locomotor. 

Athetosis is the vermicular movement described first by Ham- 
mond, observed in cerebral disease, as in porencephaly. 

Conjugate deviation is a phenomenon that is frequently pres- 
ent in diseases of one side of the brain. In this the eyes are 
directed towards one side (of lesion), with or without the corre- 
sponding rotation of the head. 

If the lesion is a simple irritative one the deviation is away 
from the side of the lesion. The first is paralytic, the latter spas- 
modic. 

PRESSURE SENSE 

Pressure sense is determined by means of weights, alternating 
one with the other, until the power of discrimination is nicely met 
with the least amount of weight. Differences of temperature 
should be excluded, also the prevention of the displacement of 
the weights in this test, and the area or part tested should be held 
in relaxed position. For making the finer tests bits of cork are 
used. 

MUSCULAR SENSIBILITY 

This test depends somewhat upon idiosyncrasy of the individ- 
ual. To exclude surface differences in testing by balancing 
weights, they can be suspended in a towel or by cords. By re- 
peated experiments, it is thus possible to determine as between 
the cutaneous sensibility (which will interfere with the test to the 
extent of two or three ounces pressure) and the muscular sense. 

The pressure sense is a composite physiological phenomenon, 
consisting of the sense of coarse movements of the limb, the pos- 
ture sense and the pressure sense. 

SENSE OF THE APPLICATION OF WEIGHT 

This is determined by the piesmeter of Beard and Rockwell, 
which instrument is made up of a cylinder, f of an inch in diam- 
eter and 3 inches long, in which is a piston kept pressed back to 



TO TKEATISE OiST NERVOUS DISEASES 

its fullest extent by a spring. 'At the end of the piston rod is a 
flat disk which is pressed against the skin. The ph3'sician then 
presses against the end of the cylinder, forciag the piston into the 
barrel, and the amount of pressure made before it is recognised 
by the patient is indicated by a scale on the instrument. In this 
connection it should be stated that there is a similar instrument, 
which is called the algometer, devised by Dr. Arthur MacDonald, 
by which pain is tested in a similar manner to that of the above 
instrument. Instead of the plain disk, however, a sharpened point 
is forced upon the part to be tested. 

SENSATIONS OF MOTION 

It may be necessary to diagnosticate diseases of the semi- 
circular canals, the vestibular nerve and its terminations, from 
affections of the cochlear nerve, which latter is the true nerve 
of hearing. Since the two nerves are so closely approximated in 
most deaf persons, it will be found that sensations of motion are 
also affected in them. So that it is chiefly where the periphery of 
the vestibular nerve is afi'ected, the patient not being deaf, there- 
fore, that abnormal sensation of motion are produced in hearing 
individuals. In this test, deafness or not should, of course, be first 
determined. Then rapidly rotate the table upon which the patient 
stands, the top of which is placed upon a pivot, as suggested by 
Sanford. In health the direction of rotation can be recognised 
when the rate is as low as two degrees per second, or even lower. 
In some deaf-mutes the sense of motion is entirely absent. This 
latter is probably a reason why deaf people seldom get seasick. 

OCULAR DISTURBANCES 

In this we examine for changes in the optic nerve, such as 
neuritis, atrophy, occurring in brain tumour, meningitis, etc. ; also 
for changes in the retina, especially concerned in specific disease 
of the nervous system. Eefractive errors are not a part of neuro- 
logical examination. Nystagmus or involuntary oscillation of the 
eyes, usually bilateral and horizontal, is present in affections of the 
cerebellum and in disseminated scleroses. It is irregular or rotary 
in type in blind persons. Nystagmus may also be congenital. 

Hemianopsia is loss of one side of the visual field, whereas 
hemiopia refers to loss of visual power in one-half of the retina. 



SYMPTOMS AND METHODS OF EXAMINATION U 

The latter term is generally used in describing peripheral dis- 
turbances, whereas hemianopsia is used in the study of brain dis- 
eases. The lesion causing hemianopsia is situated anywhere from 
the cortical centres of vision in the occipital lobe to the optic 
chiasm. In rare cases it may be necessary to study areas of ob- 
scuration of vision, as quadrants or irregular areas. Hemianopsia 
may be vertical, horizontal, bilateral, binocular, or lateral ho- 
monymous. 

^ Homonymous hemianopsia indicates blindness of the inner half 
of one field and the outer half of the other field of vision. 

Amhlyoyia indicates dimness of vision. 

Amaurosis indicates total blindness. 

Hemianopsia can be roughly determined by having the patient 
look at a fixed point, then by moving an object from without in, 
in all portions of the visual field, when, if it is not present, the 
moving object will be perceived at the proper limit. The perim- 
eter of Emerson is also used by the ophthalmologist to make these 
tests. 

Errors of refraction and exophthalmos should also be noted. 

Wernicli'e's liemiopic pupillary 172 action consists in lack of con- 
traction of the iris when a ray of light is thrown on the blinded 
side of the retina. Since the reflex centre of this arc is located 
in the primary optic centres in the pregeminum and pregenic- 
ulum, if the lesion is behind these centres, the reaction does not 
occur. If the lesion is in front of the primary centres, the inac- 
tion occurs. 

Colour Changes. — Occasionally subnormal colour perception 
exists with hemianopsia or with sector defects of the eye. Con- 
centric restriction in the field of vision and reversal of the order 
of colour field may be present and may be tested for with colour 
disks in the slide of the perimeter. Abnormalities of the visual 
fields may occur in functional disease; thus, in hysteria we may 
have complete reversal of the colour field with a constriction of the 
field of vision. The condition is likely due to defect of perception 
in this disease, as described by De Schweinitz and J. K. MitchelL 
The test for colour is made by means of coloured yarns. 

Pupillary Symptoms. — We note under this if the pupils are 
dilated, contracted, or irregular ; also seek for abrupt and frequent 
changes in the pupil and also for spasms or paralysis of accom- 
modation, etc. 



n 



TREATISE ON NERVOUS DISEASES 



Argyll-Robertson pupil is one in which there is wanting re- 
sponse to light, the power of accommodation remaining. 

A iDhenomenon called liippiis is produced when the hand cov- 
ering the e3'e, directed towards the light, is removed, the pupil at 



LEPr 







-^ 


'"^, 




- — ^\ 


iA — = 




'•^^M 


\\ 


^^^ 


h=EP>1 P-O-BJV-L-l 


^^-^ 


1 ■ -] 


\ — 


j 


^\ — 


/ 


^-?^ 


^ 


^.<' 



''/suav- 



Fig. 19.— Diagram of Visual Paths. (From Vialet, modified.) 
OP. N., Optic nerve. OP. C, Optic chiasm. OP. T., Optic tract. OP. R., Optic ra- 
diations. GEN., Geniculate body. THO., Optic thalamus. C. QtJ., Corpora 
quadrigemina. C. C., Corpus callosum. V. S., Visual speech centre. A. S., Audi- 
tory speech centre. M. S., Motor speech centre. A lesion at 1 causes blindness of 
that eye ; at 2, bi-temporal hemianopia ; at 3, nasal hemianopia. Symmetrical 
lesions at 3 and 3 would cause bi-nasal hemianopia ; at 4, hemianopia of both eyes, 
with hemianopic pupillary inaction; at .5 and 6, hemianopia of both eyes, pupillary 
reflexes normal; at 7, amblyopia, especially of opposite eye : at 8, on left side, word- 
blindness. 



SYMPTOMS AND METHODS OF EXAMINATION 73 

first contracts, and then slightly dilates, and thus oscillates until it 
settles to the original size. 

During the testing for mobility of the iris tTTe eye must be 
fixed upon a distant point, if not, the influence of accommodation 
and convergence will prevent accuracy. 

Hearing. — This is tested by means of a watch brought towards 
the ear, the point at which it is first heard to tick being recorded. 
The eye should be closed when this is being done. This test shows 
the extent of air conduction. Bone conduction is tested by using 
watch or tuning-fork. The patient being deaf, a tuning-fork 
struck, then placed over the mastoid process is heard better than by 
aerial conduction in an ear ••that is diseased in the middle portion. 
Disease of the labyrinth or nerve will, of course, destroy bone con- 
duction as well as aerial. 

Galton's whistle is a piece of brass tubing, with an internal 
diameter of less than ^^ of an inch, into which a plug can be fitted 
and drawn in or out at will. This is used in determining pitch. 

Deafness is of different degrees. We speak of this as a person 
being totally deaf, partially deaf, or having impaired hearing. 
The three terms indicate the degree of defect in the order men- 
tioned. 

Smell. — In testing the efficacy of the olfactory nerve, and in 
distinguishing acuteness, we should avoid, first, the use of any 
irritating substance, and, secondly, select pleasant odours; thus, 
the odour of violets, musk, camphor, oil of cloves, etc., should 
be placed upon cotton and applied to one nostril while the other 
one is held closed at the time. The loss of the sense of smell may 
be due either to a functional or an organic disease. Of the former, 
hysteria is an example. Anosmia is the name given to that condi- 
tion where there is loss of the sense of smell. Fracture through 
the ethmoid may cause organic anosmia. Hyperosmia is increased 
acuity of the sense of smell. Parosmia is the perversion of the 
sense of smell. 

Taste. — This is tested for by means of a sweet solution, or of 
something sour or bitter. In making the test the patient should 
be asked to protrude the tongue, the solution being dropped upon 
one side of tlie tongue, and the patient again asked to record the 
sensation before retracting tlie tongue into the mouth, otherwise 
the sensation will be perverted by impingement of the test solution 
upon adjacent parts of the mouth. A test should be applied to the 



74 THEATiSE OX XERVOUS DISEASES 

sides, back, tip, and middle of the tongue, according to the part 
desired to be tested, and is indicated upon each half separately. 

The sense erf taste can be tested electrically by an instrument 
invented by Xewman consisting of a long stem carrying two wires 
isolated from each other, at the ends of which are two little balls, 
forming the poles. The current being applied, the sense of taste, if 
present, is readily perceived in a sapid and metallic sense of taste. 
In order to prevent confusion, smell, touch, or taste, the eyes 
should be shut and the nostrils held in difficult cases. Ageusia is 
absence of taste. Hypergeiisia is increased sensibility of taste. 
Parageusia is perversion of the sense of taste. 

Reflexes. — Since these are most important they will be gone 
over again from a different viewpoint. The reflexes are divided 
into cutaneous, deep, and visceral, as noted in a previous section. 

Exaggerated responses of skin reflexes will be produced if the 
special sense organ is in an irritated or inflamed condition, or if 
they are cut ofl from central control, or if cerebral sensory areas 
are diseased. The lack of response would indicate that the nerve- 
tracts in the periphery or in the cord are injured, or that the 
special sense organs are destroyed or impaired. The skin reflexes 
have been divided in accordance with the areas most conveniently 
tested, as the supraorhital, the epigastric, over the epigastric re- 
gion; cremastei'ic, brought out by irritation over the inner part 
of the thigh; the ahdominaJ, over the sides of the abdomen; the 
plantar, obtained by irritating the sole of the foot. In the trunk 
and upper extremities we have the intercostah the inter scapular, 
the palmar, the bicipital, and in the head the conjunctival and 
pharyngeal. The skin reflexes are very easily exhausted even in 
very sensitive individuals. Therefore, the test should be made 
quickly and recorded at once before the loss occurs. 

Deep Reflexes. — These deep reflexes are muscle or tendon re- 
flexes. The knee-jerk or patellar reflex is that produced by ^tap- 
ping the ligamentum patella, which by stimulating contraction of 
the erector f emori group of muscles, produce extension of the leg. 
The jerk is due, first, to the direct stimulation of the muscles, 
and, secondly, to reflex influences. The elbow- jerk is produced 
by tapping the triceps tendon, the arm being pendant over some 
object, as the back of a chair. Extension of the forearm occurs. 
The biceps- jerk is produced upon striking the biceps tendon of 
the arm, the member being held in semi-flexion. This produces 



SYMPTOMS AND METHODS OF EXAMINATION 75 

flexion of the forearm upon the arm. Jerhs or reflexes can also 
be obtained over some of the muscles of the neck, as well as from 




SHOWING THE MECHANISM OF THE DEEP 
REFLEXES AND EXAMPLES OF THE LESIONS 
WHICH MAY INCREASE OR ABOLISH THEM 
AS ILLUSTRATED BY THE KNEE-JERK, 

DOTTED CIRCLES = LESIONS ABOLISHING 
THE REFLEXES. 

BLACK CIRCLES = LESIONS EXAGGERATING 
THE REFLEXES. 



Fig. 20. — Showing mechanism of deep reflexes ; 
also the two main types (spastic and flaccid) of 
paralysis. (From Butler's Diagnostics ) 



76 TREATISE ON NERVOUS DISEASES 

the tendons. The reflexes may be exaggerated, depressedy or abol- 
ished in nervous diseases. In making a test the part should be 
well supported and voluntary effort on part of the patient avoided. 
The chin or jaw-jerk is that produced by tapping the mental proc- 
ess of the inferior maxillary bone, the mouth being held loosely 
open, when contraction of the temporal muscles occurs to the 
closure of the mouth. It is diminished in neurasthenia. Muscle- 
jerhs are the same as deep reflexes and are also obtained by striking 
the muscle, when shortening occurs. If disease or an injury severs 
the nerve supplying the muscle, the tendon reflex is absent, but 
" humping ^' from a direct blow over the belly of the muscle may 
remain for a time. 

Afilde clonus is produced by sudden flexion of the ankle, when a 
rapid clonic movement will follow if the phenomenon be present. 
Paradoxical contraction is the sudden contraction as of the ante- 
rior tibial muscles, when the said muscles are suddenly shortened 
by movement of the extremity. These two reflexes are always 
abnormal, and indicate excess of irritability of an organic nature. 

Bull)o-cavernous reflex consists in sudden contraction of the 
ischial and bulbo-cavernous muscles caused by mechanical excita- 
tion of the glans penis. It is produced by placing the left index 
finger on the bulbous portion of the penis, and with the right 
hand striking, with a piece of paper, the dorsal surface of the glans. 
Onanoff believes that its absence is the sign of an organic lesion. 
If the sexual function is impaired and the reflex is present, the 
disease is probably of dynamic origin, and favourable prognosis 
can be given. This reflex is also styled virile reflex by Hughes 
of St. Louis. 

The anal reflex has its centre in the third sacral segment. 
It is found increased in neurasthenia and in myelitis high up, 
but is diminished in sacral neuritis and posterior scleroses. 

Visceral Reflexes. — Eye. — The liglit reflex is produced by 
throwing a ray of light into the eye, when the pupil contracts, 
to dilate again when the light is removed. The accommodation 
reflex is brought about by causing the patient to look at a near 
and a far object. In the former case the pupil contracts; in the 
latter it dilates. One eye should be covered in examining for the 
reflex of the pupil. When the light reflex is lost and accommo- 
dation remains, we have what is known as the Argyll-Robertson 
pupil. 



SYMPTOMS AXD METHODS OF EXAMINATION 77 

Reflexes of the Bladder, Rectum, and Sexual Apparatus.— 

Urination and defecation are reilex acts under control of higher 
centres. If the inhibitory influence is removed and voluntary 
control over the sphincters is lost, urine and faeces are expelled 
as soon as bladder and rectum are full. Disturbance of function 
of the pyramidal tracts will bring about this condition. The 
bladder walls may become weak, and if the compressor urethrce 
remains intact the bladder becomes distended, and we have in- 
continence of overfioio. If any of the components of the reflex 
are involved, incontinence will occur. If the motor part is dis- 
eased, the sphincters are relaxed. In case of the rectum, if the 
rectal sphincter is relaxed it is due to (as can be shown by digital 
examination here) disease of the motor part of the arc. If the 
sensory part of the arc is diseased, the patient is unaware that the 
bladder or rectum is full. Damage to arc of genital functions may 
bring about loss of sexual power and desire. 

The Surface Temperature. — It is desirable to note the local 
temperature in many diseases, in some of which this symptom is 
of special value, as in cerebral haemorrhage, infantile palsy, and 
in the various vaso-motor and trophic disturbances. In cerebral 
diseases we may find an increase or a diminution over some por- 
tion of the scalp. 

In erytliromelalgia the surface temperature is increased, espe- 
cially when the affected limb is pendant. This can be detected 
by a thermometer, which was first invented and constructed by 
Seguin. 

The Mattson's surface thermometer is an instrument consisting 
of a coil containing the mercury and extending up a tube at right 
angles to the coil. It is the best instrument that we have used. 



CHAPTER IV 

GENERAL THERAPEUTICS AND PREVENTION OF NERV- 
OUS DISEASE AND THE ACQUIREMENT OF NERVOUS 
HEALTH — HYDROTHERAPEUTICS — MASSAGE — ELEC- 
TRIC 1 TY — HYPNO TISM — CARE AND TREA TMENT IN 
CONVALESCENCE FROM FUNCTIONAL NERVOUS DIS- 
EASE—CLIMATOLOGY OF NERVOUS DISEASE 

TREATMENT AND PREVENTION OF NERVOUS DIS- 
EASE AND THE ACQUIREMENT OF NERVOUS 
HEALTH 

In the treatment of nervous disease the physician should at- 
tempt to relieve distressing sj^mptoms, or better, to secure an out- 
and-out cure, or to prevent return — prophylaxis being always the 
ideal, but which it is difficult to inculcate into the minds of or 
enforce upon people who have not once gone through suifering. 

General measures to be instituted in the care of nervous dis- 
ease are, first hygiene, then exercise, rest, diet, climate, hydro- 
therapy, massage, electricity, external and internal applications 
and measures, surgical procedures, and finall}^, the judicious use of 
drugs and of other remedial measures. 

Hygiene. — To maintain normal nervous systems in the present 
social life led by Americans would require extreme alterations in 
method of living of the majority, though gradually the cultured 
educated classes are beginning to appreciate this, and are adopt- 
ing more common-sense methods of living, which wise scientific 
doctors have been advising for so long. Methods here detailed 
are particularly applicable to the neuropathic individual, but it 
must be remembered that the nervous predisposition does not start 
de novo, and hence the suggestions to be here made can apply in 
proper measure to all active people. 

Thus, persons of neuropathic stock should not intermarry. 
Consanguinity should be avoided; nor should intermarriage take 
place betweeen families of highly nervous temperaments. Chil- 
dren should live much in the open air to develop themselves by 
78 



GENERAL THERAPEUTICS AND PREYEXTIOX 79 

natural methods of physical exercise, such as walking, boating, 
horseback-riding. The overdoing of many so-called medical gym- 
nastic exercises should be prevented. People should be taught to 
eat slowly, masticate and insalivate thoroughly, and to live on a 
wholesome mixed diet of fats, carbohydrates, and proteids. Self- 
control and obedience should be inculcated into children from an 
early age. This particularly prevents the development of hysteria, 
that disorder of the emotions. Systematic study and work is essen- 
tial; never overwork in growing youth. All reflex causes, such as 
by eye-strain, through poor light, or errors in refraction, should 
be looked to. Ventilation, if poor, will have a baneful influence 
through preventing proper oxidation and growth and nutrition of 
nerve and other tissues in the economy. The occupation should 
be carefully selected for the young; oi'ereducation is to be avoided, 
since it brings about stress upon the growins: brain and its highest 
function, the mind. Weak children should indeed be especially 
educated in accordance with their physical development and nerv- 
ous capacity. Precocious children are only more apt to develop 
breakdowns because they do overwork. The queer or eccentric 
child is the one, however, that must be well guarded if a nervous 
wreck is not to develop at adolescence. Mental overwork in them 
should largely be substituted by physical exercise. Even this can 
easily be overdone. Many people of this stamp would make 
excellent artisans or mechanics, or even labourers, and enhance 
the value of the race by such manual labour rather than by being 
advised or set to do the work of the mind such as is compassed 
in the professions. " Moderation in all things " is an old adage 
that amply applies to prophylaxis of nervous disease. This applies 
to sexual indulgence in adults in particular. Exercise is a very 
valuable proph3iactic measure for them. Luetic infection is the 
one prominent single misfortune that can happen to an individual; 
for even if treated to the full, there still lurks remote toxines 
within the blood which at the degenerative period of life cause 
neurasthenia, hysteria, or grave organic or suborganic disease, 
which seldom can be entirely relieved. The overuse of tea, coffee, 
condiments, tobacco, or alcohol must be remembered as causes of 
various functional and organic diseases, such as optic atrophy or 
chronic neuritis. ^lental and physical trauma; poisons, as lead 
or mercury; or the infective fevers, are all causes of various 
nervous disorders. Alcoholic abuse, it should be repeated, stands 



80 TREATISE ON NERVOUS DISEASES 

next to syphilis as a cause of a legiori of diseases of the nervous 
system. At least eight hours of sleep should be had in twenty- 
four hours by every healthy man. 

Diet. — As indicated above, nitrogenous food should be given 
in abundance to the nervous, since there is waste in them of nu- 
clein and other proteid substances from the nerve-cells. Fats 
are next in importance; carbohydrates least, and they also fre- 
quently interfere with digestion, since it requires more caloric, and 
therefore nervous energy to oxidize this class of foodstuffs. 
Water should be drunk freely between meals, and even a glass of 
water at the meal is a desideratum, since certain salts of food need 
the chemical action of water to convert them into soluble chem- 
ical substances. The obese should not eat or drink as freely as a 
spare person. If muscular exercise is indulged, then the total 
amount of food should be increased. If the patient is consti- 
pated, green vegetables, farinaceous foods, or an orange before 
breakfast are valuable remedial measures in dietary. The best 
foods are meats — beefsteak and fowl; also eggs, fish, milk, but- 
termilk, and cocoa; stale bread, to which can be added plenty of 
butter. Metal workers should have plain drinks and alkaline 
waters. It must b^ remembered that adults cannot take so copi- 
ously of milk as children. The use of alcohol is baneful for the 
nervous body. Some claim it may increase capacity for work, but 
I am perfectly sure this is not the case. In disease with tempera- 
ture it is, of course, of value. 

" Generally nervous " still applies to a class of irritable persons 
annoyed by trifles, yet not truly neurasthenic nor hysterical. In 
all three of the latter states, however, the patients can and should 
take large quantities of proteid food, to which should be added 
the heat-giving foodstuff fats as much as can be easily digested, 
since these patients always complain of being cold or chilly at the 
slightest exposure. Some nervous persons cannot take sweets with- 
out producing headache, rheumatic pains, or disorders of digestion, 
due to the fermentation produced and acid condition of the blood 
(uricacidsemia) following. In such people the diet should ex- 
clude carbohydrates and include meats, fish, oils, as cod-liver or 
olive; also cream, milk, oysters, and even pork. Spinach is an 
excellent food for the neurotic, since it is laxative and contains 
a goodly proportion of iron. The white of an egg added to beef- 
tea, to which can be placed in addition some form of peptonoids, 



GENERAL THERAPEUTICS AND PREVENTION 81 

is very nutritious. Besides the stale bread indicated, in which fer- 
mentation is complete and the individual elements better dis- 
persed, the nervous person can use the special forms of breads in 
which the starch has largely been removed. These give the gastric 
content a release from overtaxation in digestion of the carbo-* 
hydrates. Practically, however, the patient cannot take these 
breads for any length of time, since they are unpalatable. 

If a rigid diet is desirable make it as follows: Milk, oysters, 
butter, eggs, raw or soft, cocoa, graham or gluten bread, beef, 
fowl, mutton, lamb, or fish. Among vegetables spinach, lettuce, 
string-beans, Brussels sprouts, or stewed fruits are the best. The 
neurotic person, from the subjective craving of nature (boulimia), 
is liable to eat too much. Hence this should be guarded against, 
since overloading the stomach in them may cause gastrectasia, 
an added mechanical cause for indigestion. Tea, coffee, and alco- 
hol are baneful in effect upon the franMy nervous person. Over- 
use of the alkaline mineral waters should be avoided, since disturb- 
ance of the normal acid secretion of the stomach will be brought 
about and add to distress. Three to four pints of plain water 
should be drunk per diem. Dryness of or desiccated nervous 
systems cause instability of function. 

Exercise. — The value of exercise, if taken out of doors, as in 
rowing or horseback-riding, where the mind cannot run in special 
grooves, is a certain preventive of nervousness beyond calculation. 
The exercise should not be violent in brain-workers — i. e., they 
should not go into severe athletic training. Even the majority of 
youth or of adults cannot do well both physical training and men- 
tal work of the highest sort. Nervous persons need exercise asso- 
ciated with interest to the mind; hence the individuality of the 
pleasure of one person as compared to another must be borne in 
mind, and not too strict rules laid down by the physician. Gym- 
nastic exercises indoors, as a rule, do little good from the fact 
of the monotony of the procedure entailed. The mind must be 
properly exhilarated with it all. Walking is a valuable form of 
exercise, since it is moderate, and movements of the arms bring 
into play the muscles of the chest. Horseback-riding is the very 
best exercise the nervous patient can take, since it carries the pa- 
tient out into the fresh air, expands the chest, gives free use of the 
arms, and does not require the extremes of exertion as with other 
forms of exercise. Then the spinal cord is not drawn upon so 



82 TREATISE OX NERVOUS DISEASES 

heavily in expending the little reserve of nervous energy the neu- 
rotic holds claim to as does walking, bicycling, golfing, and the 
like. Exercise should be cut down much after the degenerative 
period of age has set in (i. e., after forty) if a person wishes to 
live a long life. 

HYDROTHERAPEUTICS IN NERVOUS DISEASES 

This important adjunct to neurological care of the many cases 
coming under our observation is important for the physician and 
nurse to know well. The proper external use of water aids much 
the general treatment of nervous disease. The effect of water be- 
sides the hygienic place, and often the favourable mental influence 
upon the patient, as in cases where neurasthenic and hypochondri- 
acal phobias exist, is mainly due to reflex action upon the nervous 
system. The " reflex " arcs so patent in the symptomatology of 
organic diseases of the central and peripheral nervous systems we 
are apt to let pass by when we are caring for the so-called func- 
tional diseases ; whereas in them can be found the reflex guide-posts 
to the treatment of the case that may be cured. In organic dis- 
ease, it must be re-enforced, we have the grosser expressions of 
what scientiflc clinical medicine behooves us to search for in the 
very incipiency. And it is here in place to ^ay that the scientific 
physician will ever be the leader in progress, albeit medicine, for 
the very reason that we deal with life, can never be a true science. 
Much of the treatment at Carlsbad is scientific ; a great deal of the 
good results are from the engendered mental buoyancy which we 
must recognise. With these well-balanced therapeutic ideas kept 
perfectly clear in mind, the physician of largest attainments will 
use bathing freely more and more conscientiously until he learns 
the true value of the bath in its physical effects on the body, sick 
or well. 

Turkish Bathing. — The origin of Turkish bathing, so peculiar- 
ly associated with the religious rites of the oriental people, is quite 
as much iii niibihus as is the origin of language. The effects of 
dry heat are finally to stimulate hyperaemia of the surface of the 
body, to cause hypercaloria and hyperhydrosis. As the heart is 
stimulated by increase of temperature, that organ must be very 
competent before a patient is relegated to this initiative step of 
the Turkish bath. Indeed the heart should be toned up by digi- 
talin, strychnine, or strophanthus when there is the suspicion of 



HYDROTHERAPEUTJCS 83 

cardiac weakness. A patient Avith pronounced valvular disease 
should be prohibited I'rom Turkish Ijathing. Persons suffer- 
ing from obesity or interstitial nephritis may be greatly alleviated 
of distressing subjective phenomena of vertigo, headache, and de- 
pression by judicious use of Turkish baths. This beneficial effect 
must be due to elimination of toxines always retained in such 
cases. 

In anhydrosis, as in myxoedema, or in cases of atrophic dry 
skin I have so often seen in women at the climacteric suffering 
from general nervousness, Turkish bathing does a great good. In 
cases of neurasthenia ierminalis I have seen much improvement 
through this form of bathing. 

Hystero-neurasthenia in persons of gouty diathesis, on the 
other hand, are not benefited at all by the Turkish or Russian 
baths. 

Details of the Turkish Bath. — Like the massage we use in 
America, which is the resultant of selection from the best methods, 
the Turkish bath is modified as we use it for best therapeutic 
results. The patient should have at least two hours to give to the 
bath. This will allow amply for the one and three-quarter hours 
which should practically be the time consumed in the procedure. 
The patient is at first sent to the dry hot-air room, where he sits 
in a reclining chair, keeping perfectly quiet and relaxed. If he 
reacts favourabl}^, beads of sweat will soon begin to come to the 
surface of the body, which is always a favourable aspect. Should 
the patient complain of sense of faintness, the application of cold 
cloths to the head by the attendant is directed; also the drinking 
of cool water will do much to relieve this symptom and to hasten 
hydrosis. As before stated, the patient should be allowed to re- 
main some fifteen or twenty minutes. The temperature of the 
room is kept up by means of hot water to the average of 153° 
F. In cases of obesity, the patient may next be taken to the 
hotter room adjacent, the temperature being as high as 175° F. 
The attendant must constantly observe the case taking an initial 
bath in order to avoid any ill effects of idiosyncrasy. The patient 
is next taken to the rubhing room in moderate temperature and 
placed upon a marble slab on his back, with his head and heels 
protected by cushions or sponges. 

He is then given a thorough surface massage by the attendant, 
the general movement being from periphery to the trunk. With 
G 



U TEEATISE OX ' XEEYOUS DISEASES 

this there is a series of slapping motions with tlie palms of the 
hands^ which greatly stinuilates the circulation. The back is then 
treated in the same fashion after the patient is placed in the 
prone position. The water from a hose at about the tempera- 
ture of 105° E. is frequently deluged upon the subject with some 
considerable force during the manipulations. He is finally 
" soaped over '' thoroughly and again '' washed down " when he 
is prepared to enter the steam-bath. Then the "' shower '' is had, 
or he takes the " plunge '' in the bath, at the discretion of the 
physician. 

In the steam-hath lies the modification and blending of the 
Turkish and Russian baths used to-day. The patient enters the 
door and quickly proceeds to the opposite side of the room, where 
.he sits on the marble slab quietly for about five minutes: this is 
likely to be the most discomforting part of the entire procedure, 
and the patient should be carefully watched by the attendant in the 
first entrance, for there occasionally comes a sense of suffocation, 
which is more a mental symptom than that it is due to lack of oxy- 
genation of the blood. Otherwise at this stage there is a comfort- 
able feeling, the sweat seeming to pour from the individual, which, 
in reality, is not so. but is due to condensation of vapour upon the 
body. The temperature of the body is actually reduced by this part 
of the bath, and this is the only reason why the vapour part of the 
bath should be so short. 

The shoirer-hath should be substituted in all cases of first treat- 
ment in order to gain the confidence of the patient in the rather 
shocking changes. The shower-bath is administered by a series 
of sprays tempered to the patient physically, and it is essential 
that the water should pour in these fine streamlets upon the 
head as well as the rest of the body, else there may be a tendency 
to congestion of the brain and its membranes. Temperature 
should range from 65'' to 85° E. If the plunge is taken, the 
patient should immediately immerse himself in the pool. A 
good way to do this is by diving, if he is familiar with the water. 
He should remain in the water three or four minutes, the aver- 
age temperature being 65° E. The patient is next dried 
and rubbed in the standing posture by the attendant. He is 
then wrapped in a sheet and blanket and placed upon a couch 
or bed. to lie quietlv for at least half an hour, sleep usually 
following. 



HYDROTHEHAPEUTICS 85 



HYDROTHERAPEUTICS-C^o«j;Vn«<ec£ 

Water may be used either as a tonic or as a sedative. 

As a tonic we employ cold plunges, shower-baths, various forms 
of douches, as Charcot's and the Scottish cold sitz-bath, salt baths, 
either sea or artificial, and short cold packs. These all have a 
stimulating and tonic effect. In giving them, especially to weak 
people, it is best to begin with warm water and gradually lower the 
temperature. Showers and douches are the most stimulating. A 
reaction should always be obtained by vigorous rubbing afterward. 

For the cold plunge, the patient immerses himself in the bath 
of water at a temperature of 60° to 70° F., and at once emerges. 
He should then be rubbed vigorously. 

The shower- or rain-hath consists in allowing water to fall on 
the body from a height for one or two minutes while the feet are 
in warm water. Friction of the body should be kept up during 
this process. ■ • 

A Charcot douche is given by directing a solid stream of water 
with force upon the back of the patient. 

By the Scottisli douche we mean alternating a cold douche with 
a warm or hot one. 

Cold pachs are given by wringing a sheet out in cold water, 
wrapping about the patient for a few moments, when it is re- 
moved and the patient put to bed and rubbed. 

An artificial' salt hath may be made by putting 25 pounds of 
salt (XaCl) in 30 gallons of water (2 per cent). It may be warm 
or cold. 

To obtain sedative effects we may use the lukewarm bath, wet 
pack, hot sitz-bath, hot compresses, and drip-sheet. 

The lukewarm hath is given at a temperature of 95° to 98° 
F. for ten to twenty minutes. 

To give a wet pack, spread a large, thick blanket upon the 
bed ; upon this is laid a sheet wrung out in water at a temperature 
of 40° to 60° F. The nude patient lies upon this and the 
sheet is wrapped smoothly about him, not including the head and 
feet. The sheet must be carried between the legs and brought 
evenly in contact with the body. The blanket is then folded over 
him, with others added if desired. Hot-water bottles may be 
placed at the feet and cold compresses to the head. The patient 
lies in this for half an hour, and is then thoroughly rubbed. 



86 TREATISE OX XEEVOUS DISEASES 

The Drip-Sheet. — ^.Have a basin of water at 65° F. Put in the 
basin a sheet. The patient stands in comfortably hot water. Have 
ready a large soft towel and iced water. Wring out the towel in this 
and wrap it around the head and back of the neck. Standing in 
front of the patient, the sheet is seized by the two corners and 
thrown about the patient, who holds it at the neck. It is then 
smoothed out over the body; next loosened, dropped, and the pa- 
tient is instructed to lie down on a blanket, which is wrapped 
about him. Dry thoroughly with coarse towels, wrap in a dry 
blanket for a time, then put to bed. The water should be grad- 
ually cooled day by day until it is 55° F. 

The bath, pack, and drip-sheet are valuable remedies for in- 
somnia. 

A hot sitz-hath consists of water at a temperature of 100° to 
125° F. In this the patient sits from twenty to thirty minutes. 

Hot compresses are often used for the relief of local pains and 
congestions. 

MASSAGE 

Massage has been used as a therapeutic agent in more or less 
crude fashion for centuries. 

The wrestling matches of the Greeks left many a lame back or 
joint which their rubbers dissipated by manipulations. We all 
know, too, the uses of rubbing in alleviating the sprains and bruises 
of our army of college athletes. 

By greater refinement in the modus operandi of massage, and 
by very careful analysis of the effects to be obtained by each indi- 
vidual movement, this useful adjunct has been in recent years 
placed on a much higher plane in the therapeutic arts; indeed, in 
some instances, in expert hands it has almost amounted to a sci- 
entific basis. 

Schools of massage have been established where lectures are 
given in the larger cities of this country, also thorough practical 
work is obtained during several months' course required to become 
experienced in rubbing. At the end of this time an examination 
is had, when a certificate is given entitling the holder to recogni- 
tion by the physician. Then a course in electricity is added to 
complete the training of one who chooses the vocation of mas- 
seur or masseuse. The two (massage and electricity) go so 
completely hand in hand in the treatment of the nervous mal- 



MASSAGE 87 

adies, where they are chiefly of value, that it is necessary to be 
able to administer either one or both under the direction of the 
medical man. 

Notably in American schools very good training is given, but 
also abroad, especially in Germany and Sweden, in which latter 
country the series of movements bearing the name of Swedish 
are perhaps best known in a general way. In America all these 
very intricate movements have been somewhat modified ; and while 
the general tendency is towards definite ends, yet the extremely 
rigid mechanical side of massage is largely done away with, and 
we have a more perfect system, much better suited to the delicate 
human organism. 

The Five Sets of Movements of Massage. — 1. Effleurage is the 
gentle surface stroking of the part which quietly starts the cir- 
culation before the more vigorous. 

2. Friction is then begun. This latter consists in a firmer 
and deeper pressure-rub than the" preceding movement. 

3. Petrissage, which is a very deep kneading of the part and 
completes what has been begun by 1 and 2. It is essential in 
petrissage to hold firmly to the skin and to make this rub the 
subcutaneous tissues, while the last in turn presses the muscles, 
and so on until the soft parts are so manipulated, squeezed against 
the bones of the patient, that a veritable pushing on all of the 
liquids (blood and lymph) takes place; also, indeed, of some of 
the semi-solids, which are urged to disintegration and their ulti- 
mate particles swept on in the hurried circulation, to be oxidized 
or converted into energy, or to be excreted, instead of remaining 
in the body as sources of irritation in the form of what we call 
leucomaines. 

4. After this thorough application a movement, not so very 
essential, is yet quite often used as a final stimulator of the circu- 
lation where it is extremely sluggish. It consists of tapotemcnt 
or tapping in a rapid vibratory manner with the balls of the 
fingers of one or both hands held gently closed, similar to the 
position of holding a pen. 

5. Xext and last comes effleurage ?gain, by which the harder 
rubbing now reached shades ofl* to less vigorous frictions. These 
are soothing to the part and to the patient generally, while they 
also equalize the blood circulating in the superficial tissues. Then 
the member is immediately covered with a light woollen garment, 



88 TREATISE ON NERVOUS DISEASES 

and when the entire body is so manipulated the patient rests for 
an hour. 

Modified Swedish movements, passive then active {without and 
with muscular resistance of the patient), are often instituted after 
a course of general massage of some weeks' duration. We are 
now speaking of general rubbing or applying the art to the entire 
body, as in cases of neurasthenia, where partial or the complete 
" rest cure '^ is being systematically carried out. 

How to " Rub " a Patient. — First the subject is required to 
thoroughly relax all muscles; then he is placed on the right side, 
and the manipulations are begun on the left foot, toes, ankle, 
thigh, hip, and buttock in turn, using all the five movements de- 
scribed over each part, varying the time and duration of each in 
proportion to the size, rigidity, and amount of muscle or other 
soft tissues present. The patient is then asked to turn towards 
the opposite side, and the right foot, leg, thigh, and buttock are 
rubbed in the same thorough fashion. 

Gradually one set of movements dovetail into the other, and 
the patient's extremity becomes almost a part of the rubber, as does 
the dough of the housewife; and yet you note that by the time 
the limb is finished every nook and cranny has been gone over, 
leaving a beautiful glow of the surface in evidence of the vigour 
set up in the circulation of the blood. 

Next the left fingers, forearm, arm, and shoulder are first 
given the long sweeping effleurage, followed again by the rest of the 
detailed jnovements described; but the eye has to follow quickly 
to appreciate the rapid changes, so much a part of the manipu- 
lator does the patient become. Four or five minutes will suffice, 
and then the right arm is taken up. After this we request the 
patient to lie on the abdomen with a pillow placed under for better 
resistance. The long series of strokings down the vertebral gutters 
made alternately with the fingers of each hand spread on either 
side of the spinous processes. Then comes a series of circular 
frictions down each recti group with one hand, then a spreading 
movement from the spines outward with the balls of both thumbs ; 
next a firmer petrissage with both hands, followed by that motion 
with the palms of both hands alternately run down either side of 
the spinal column, giving a delightful sensation, while the final 
effleurage finishes and the patient is requested to turn on the broad 
of the back, the pillow being removed. 



MASSAGE • 89 

The chest movements consist principally of two : a firm strok- 
ing, following the ribs from the sternum out and down, and of 
firmer petrissage, in which the balls of both thumbs play an im- 
portant role, and can be so dextrously done as to be not at all 
painful, which occasionally happens with the beginner. 

The abdomen is rubbed as follows (this is very important and 
difficult to acquire) : the thighs are flexed on the abdomen and 
legs on the thighs in order to relax the anterior abdominal walls. 
The effleurage is simple enough, but it requires tact to knead thor- 
oughly without tickling. Begin this over the small intestine and 
work with both hands in a ^^ spanning ''-like manner. Then start 
at the caput coli and work along the ascending transverse and 
descending coli, one hand following the other in rotary motions. 
Again effleurage follows, and, as pointed out above, if constipation 
is an indication to be met, that series of rapid vibrations described 
will aid much towards the cure. As a rule, the face, head, and neck 
are not rubbed in ordinary work. Where especially requested, it is 
given by a series of strokings and kneading movements in the 
direction of the venous circulation. It should be stated that in 
all movements the greater pressure shoulrl be from the periphery 
to the heart — i. e., centripetal in character. The patient is now 
allowed to have a quiet sleep. 

The salient points of massage are for the masseur to keep his 
hands soft, clean, dry, and warm. 

A general rub should last from one half to one hour, preferably 
about 10 A. M., or at bedtime. If electricity is used, give it at the 
opposite hour. The patient should rest at least three-quarters of 
an hour afterward. In orthopaedic work a maxim obtains — viz., 
" to tighten a loose joint rub easy, to loosen a firmly fixed joint 
rub hard and deep.^' The relation of gymnastics to massage 
we have only time to hint at; suffice it to say they are closely 
allied, and the former are perhaps of greatest value in lateral 
curvature of the spine and in aiding chest expansion in lung dis- 
ease. These regulated movements should also be under observation 
of the physician, 

It has been pro^'ed that the renewal of the epithelium of the 
alimentary tract is made more active under massage, and that it 
stimulates peristalsis. Blood-pressure rises after massage, and 
Dr. J. K. Mitchell's investiaation ^ shows that the blood elements 



American Journal of the Medical Sciences, May, 189^. 



90 TREATISE OX XERVOUS -DISEASES 

are put into more vigorous circulation during and after this treat- 
ment. Massage is of great value for the surgeon in getting rid of 
exudates about old fractures. 

As to the matter of technique — of course some become more 
skilled than others, but any person using tact and practice will 
learn to rub well. The therapeutic results obtained from massage 
we have not time to consider further, except to mention the very 
frequent relief of neuralgia by its careful use. 

Contra-indication to Massage. — It should not be administered 
for an hour after a meal. Fever is a contra-indication to massage. 
Enlarged and thrombosed veins should not be rubbed^ else a great 
risk of setting up a local active inflammation ensues, or that par- 
ticles (emboli) may be carried on to some important organ, as 
the brain, causing paralysis or other serious results. Tumours, 
especially malignant ones, should not be manipulated for fear of 
exciting them to more rapid growth and metastasis. If massage 
is extremely irritating after a fair trial it should be discontinued. 
There will occasionally be found one in fifty who is made worse 
by rubbing. In these persons we must resort to gymnastics alone 
or to electricity. The pregnant woman should not be rubbed about 
the abdomen; and it is advisable to abstain from abdominal mas- 
sage during menstruation, also in any case of acute pelvic disease. 
Bimanual pelvic massage may be of value in chronic cases with 
fixation of the uterus from old adhesion.^ 



MUSCULAR MOVEMENTS 

Regular muscular movements, according to a fixed schedule, as 
first used by Weir Mitchell, but since elaborated by Fraenkel. are 
of value in the treatment of muscular inco-ordination. The exer- 
cises should be performed with care and precision twice daily. 

The following schedule, based upon that of Fraenkel- and 
Hirshberg, is recommended by Dana : 

Exercises for the Hands and Feet. — 1. Sit in front of a table; 
place the hand upon it, then elevate each finger as far as possible. 
Then raising the hand slightly, extend and then flex each finder 



' For more detailed and exhaustive study the works of William :^rurrel, 
M. D., F. R. C. B., on Masso-therapeutics. 1890, and of Emil Kleen, M. D., 
Handl)ook of Massage, are recommended. 

2 The Treatment of Tabetic Ataxia, etc., 1903. 



MUSCULAR MOVEMENTS 91 

and thumb as far as possible. Do this with the right, then with 
the left. Repeat once. 

2. With the hand extended on the table, abduct the thumb 
and then each finger separatel}' as far as possible. Repeat three 
times. 

3. Touch with the end of the thumb each finger-tip sepa- 
rately and exactly. Then touch the middle of each phalanx of 
each of the four fingers with the tip of the thumb. Repeat three 
times. 

4. Place the hand in the position of piano-playing and elevate 
the thumb and fingers in succession, bringing them down again, 
as in striking the ke3^s of the piano. Do this twenty times with 
the right hand, and the same with the left. 

5. Sit at a table with a large sheet of paper and pencil. Make 
four dots in the four corners of the paper and one in the centre. 
Draw lines from corner dots to centre dot with the right hand; 
same with the left. 

6. Draw another set of lines parallel to the first with the right 
hand; same with the left. 

7. Throw ten pennies upon the paper. Pick them up and place 
them in a single pile with the right hand, then with the left. Re- 
peat twice. 

8. Spread the pennies about on the table. Touch each one 
slowly and exactly with the forefinger of the right hand, then 
with the forefinger of the left. 

9. Place an ordinary solitaire board on the table, with the 
marbles in the groove around the holes. Put the marbles in their 
places with. the right hand; same with the left hand. Patient may, 
with advantage, practise the game for the purpose of steadying 
his hands. 

10. Take an ordinary fox-and-geese board with holes and pegs, 
and beginning at one corner place the pegs in the holes, one after 
the other, using first the right hand and then the left. 

Exercises for the Body and Lower Limbs. — 1. Sit in a chair. 
Rise slowly to the erect position without help from cane or arms 
of chair. Sit down slowly in the same way. Repeat once. 

2. Stand with cane, feet together: advance the left foot and 
return it; same with the right. Repeat three times. 

3. Walk ten steps with cane, slowly. Walk backward five steps 
with cane, slowly. 



92 TREATISE OX NERVOUS DISEASES 

4. Stand without cane, feet a little spread out, hands on hips. 
In this position flex the knees, and stoop slowly down as far as 
possible ; rise slowly. Repeat twice. 

5. Stand erects carry left foot behind, and bring it back to its 
place; the same with the right. Repeat three times. 

6. Walk twenty steps, as in Exercise Xo. 3: then walk back- 
ward five steps. 

7. Repeat No. 2 without cane. 

8. Stand without cane, heels together, hands on hips. Stand 
in this way until you can count twenty. Increase the duration 
each day by five, until you can stand in this way while one hundred 
is being counted. 

9. Stand without cane, feet spread apart; raise the arms up 
from the sides until they meet above the head. Repeat this three 
times. With the arms raised above the head, carry them forward 
and downward, bending with the body until the tips of the fingers 
come as near as they can be safely carried. 

' 10. Stand without cane, feet spread apart, hands on hips; flex 
the trunk forward, then to the left, then backward, then to the 
right, making a circle with the head. Repeat three times. 

11. Do Xo. 9 with heels together. 

12. Do Xo. 10 with heels together. 

13. Walk along a fixed line, such as a seam on the carpet, with 
cane, placing the feet carefully on the line each time. Walk a 
distance of at least fifteen feet. Repeat twice. 

14. Do the same without cane. 

15. Stand erect with cane; describe a circle on the floor with 
the toe of the right foot; same with the left. Repeat twice. Be- 
tween the fifth and sixth exercise the patient should rest for a few 
moments. 

ELECTRICITY 

Physics. — The laws which govern the electrical current are 
similar to those governing the flow of water. If two vessels one 
above the other and connected by a tubing, and water is poured 
into the higher vessel, it will tend to run to the lower vessel ; the 
water will thus generate force or capacity for work which is called 
poiential. The fluid in the lower vessel would also tend to reach 
a low level, but the force would not be so great as that of the 
higher vessel; at sea-level would be zero potential. The difference 



ELECTRICITY 93 

in force exerted between these two bodies of water would be their 
difference in potential. 

By means of certain agencies (chemical change, friction) elec- 
tricity is separated into positive and negative electricity, the posi- 
tive being of higher potential than the negative, the positive tend- 
ing to flow towards the negative and thus cause an electric current. 
The zero point of an electrical current is the earth. 

Volt. — The force which starts the column of water flowing is 
gravity ; that force which causes an electric current to flow is called 
electro-motor force (E. M. F.). The unit of measurement of this 
is called the volt. 

Ohm. — Some substances are much more pervious to the passage 
of water than others. This is so with electricity. Conductors ^er- 
mit the electric current to flow easily. Metals, plumbago, dilute 
acids, saline solutions, water, and living animals are good conduc- 
tors in the order mentioned, ^^o^i-conductors or insulators do not 
permit free passage of electricity — such as rubber, glass, silk, 
resins, and dry air. 

Just as water encounters resistance as it flows through a pipe, 
so does electricity meet resistance as it passes along a conductor; 
and this resistance will depend upon the length, composition, and 
area of cross-section of the conductor. Thus a current passing a 
short distance through a good , conductor of large area of cross- 
section will meet with less resistance than a current when passing 
through a poor conductor with a small cross-section area, or a long 
distance. The unit of resistance is called an ohm. 

Ampere. — The current strength (C) is dependent upon Ohm's 
law, which is that the current strength is equal to the electro-motor 

force divided bv the resistance ( C := 1^' — '-) . The current 

strength is measured in amperes. In medicine we use i-jnro P^^^ 
of an ampere, called a milliampere. When electricity is confined, 
as by means of insulators, it is said to be static. 

Physiology. — Electricity acts in various ways upon living tis- 
sues. It possesses the power of cataphoresis — i. e., it may carry 
solutions through the tissues in the direction of the current. By 
this means cocaine for anaesthesia and various other drugs, as mer- 
cury, may be carried into the tissues. Electricity may also pos- 
sess the power of electrolysis or chemical decomposition of tissues 
at the electrodes. By this destruction of nsevi, or small tumours, 



94 TEEATISE OX NEKVOUS DISEASES 

may be brought about. Electricity also causes a modification of 
nerve-excitability known as electrotonus. In the vicinity of the 
anode the excitability is lessened — anelectrotonus ; while at and 
in the vicinity of the cathode the excitability is increased — cath- 
electrotonus. When anelectrotonus is made to suddenly dis- 
appear by the breaking of the current at the anode, cathodal 
increase occurs, and the nerve is thrown into a condition of cath- 
electrotonus. 

Electric currents also cause muscular contraction, and this is 
produced by a sudden increase or decrease of electrical excitement 
in the muscle or the nerve supplying it. If this is done but grad- 
ually no contraction results. The most powerful contraction is 
therefore caused by the voltaic alterative. It is produced by sud- 
denly reversing the current direction, so that a nerve or muscle 
that was in a condition of anelectrotonus is thrown into a condi- 
tion of cathelectrotonus, or from a state of — excitability to 
one of -|- positive, and vice versa. By simple closure and open- 
ing of the circuit the increase is only from to -|- excitability 
and to — excitability, which, of course, is not so great a vari- 
ation. 

The galvanic current produces all of these properties in more 
marked degree than does the faradic or static. In the latter two 
forms the influence of the current, due to constant interruptions, is 
so brief in duration that they are practically only used to cause 
muscular contraction and relieve pain respectively. 

A degenerating muscle loses its power of response to static elec- 
tricity first, next to faradic, then to simple opening and closing 
of the galvanic current, and finally to the voltaic alterative. 

Diagnosis and Prognosis. — In many diseases of the nervous 
system, particularly cord diseases, the muscles "and nerves, when 
submitted to electrical stimulation, act differently to normal mus- 
cles and nerves. This electrical irritability may differ in two ways, 
quantitatively and qualitatively. 

Change in quantity implies a diminution or decrease in irrita- 
bility, while change in quality that there is change in the cliaracter 
of the contraction. 

Quantitative Change. — Simple increased irritahility , or that in 
which the muscle or nerve responds to a weaker current than nor- 
mal, is met with most frequently in tetany. Decreased irritahiUiy, 
or that in which a stronger current than normal is required to pro- 



ELECTRICITY 95 

duce contractions, occurs in mild cases of neuritis, and occasion- 
ally in long-standing central p{'iral3'ses. And these conditions are 
generally the same for both currents. 

Quantitative CJi.anges — Examination. — To ascertain these: if 
the paralysis is unilateral, the weakest current will cause con- 
traction on the normal side should be learned; then the strength 
of the current that will produce the same result on the diseased 
muscles is determined, and the two compared. 

If the disease is bilateral the reaction may be compared with 
the reaction of a normal person of similar physique, or judged by 
experience as to the strength of current usually required in the 
particular muscles tested. 

Qualitative changes consist of reaction of degeneration (DeR) 
and of the myotonic muscular reaction, the former being found in 
certain peripheral palsies, and therefore, when present, always in- 
dicates a lesion situated in the peripheral motor neurone — i. e., 
motor cell of medulla or cord — or in the axones forming the motor 
nerves that come from this motor neurone; while the latter {myo- 
tonic muscular reaction) is a symptom of the clinical disease myo- 
tonia congenita. (See Thomsen's disease.) 

Reaction of degeneration may be, according to the degree of 
disease of peripheral motor neurones, partial or complete. 

Complete reaction consists of (a) rapid loss of the power of 
the muscle and its supplying nerve to react to the f aradic current ; 
(h) a brief period of quantitative increase followed by a decrease 
when they are stimulated by the galvanic current; (c) the ?iodal 
change — i. e., instead of the short, jerky contraction caused by 
the stimulation of the healthy muscle or nerve by the galvanic 
current, the contraction is slow, wavy, and at times tetanic; and 
(d) the serial change when the muscle alone is subjected to gal- 
vanic stimulation. 

The partial or serial change depends upon a difference in the 
way the muscle reacts to different poles of the battery, normally 
the weakest current that will cause a muscular contraction is when 
the circuit is closed with the cathode on the muscle (cathodal 
closing contraction CaCLC) ; a stronger current will cause an 
anodal closing contraction (AnCLC), etc. If we represent anodal 
opening contraction by AnOC and cathodal opening by CaOC, the 
normal formula will be 

CaClC>AnClC>AnOC>CaOC 



96 TREATISE OK NERVOUS DISEASES 

The serial change in complete reaction of degeneration (DeR) 
consists of an increase of the AnClC and AnOC over the CaClC ; 
so that one formula would read AnClC = AnOC CaClC CaOC, or 
as follows: AnClO AnOOCaClOCaOC. 

Partial DeR is more usual than the complete as just given, and 
may consist of nothing but the loss of faradic irritability and the 
?iodal change, the series remaining normal. The series may be so 
changed, however, that AnClC = CaClC. In partial reactions the 
nerve usually responds normally. 

Examination for the Presence of DeR. — Here we first use the 
faradic current as when testing for quantitative changes. Then 
use the large galvanic electrode over the sternum, and the other, 
a small one, over the muscle. This will show the minimum 
strength of current necessary to cause CaClC and AnClC. If 
a milliamperemeter is attached, we can note the number of 
milliamperes required ; or if not, by noting that the current which 
causes CaClC will not cause AnClC, or vice versa, or that they 
are equal. 

Another method consists in making the electrode positive 
or negative alternately, using the same strength of current 
and noting the difference, if any, in the degree and intensity 
of contractions. In all of these tests there should be an interval 
of several seconds permitted between opening and closing the 
circuit. 

The myotonic reaction is due to a much increased irritability; 
mild faradic and galvanic currents produce contractions that are 
tetanic in character, hollows and ridges in the muscle being fre- 
quently produced. In the case of the galvanic current AnClC 
becomes equal to or greater than CaClC. When the galvanic cur- 
rent is allowed to pass without interruption through a muscle, 
rhythmical contractions, travelling from negative to positive pole 
occur. 

Electricity may at times help in giving a prognosis — e. g., 
complete DeR is only present when extensive damage has been 
done; the prognosis is more grave than when the reaction only 
shows partial DeR, particularly when in the clinical signs the 
anterior horns of the cord show involvement. Per contra it is 
better in nerve-trunk lesion per se. Prognosis is best in cases where 
no serial changes occur. In cases where only feeble AnClC can 
be elicited, it is usually hopeless. 



ELECTRICITY 97 



GENERATION OF ELECTRICITY FOR PRACTICAL 

THERAPY 

Electricity is generated in a cell composed of two opposing 
elements, one being called positive, the other negative,' hoth of 
these being placed in the same solution, a good conducting medium, 
as, for example, sulphuric acid. Then the current is given off 
from the battery at the softer metal — for instance, the zinc. A 
current thus set up passes from the negative to the positive pole 
within the '^ cell,'' so called, thence out a conducting wire to the 
electrode or pole, designated the positive pole, and from which the 
current passes when applied to the human body. The pole or 
electrode from which the current passes to the other conducting 
wire back to the " cell " is called the negative or active pole of the 
battery. This apparatus, simply described, is designated a galvanic 
or chemical instrument, and is most potent for action upon the 
tissues. A practical method of determining which pole is negative 
or not is perhaps best made by placing the electrodes in water ; the 
one from which bubbles escape is the negative, active, or electro- 
lytic pole. A good point also for remembering which pole is the 
more active is to be guided by the paradoxical fact that the " nega- 
tive pole " is the positive one for action, while the " positive pole " 
is the negative one in regard to its effect upon human tissues. Gal- 
vanic electricity produces profound action upon the human body, 
and is the one used where there are the so-called degenerations, 
if electricity has been prescribed for the case. 

SOME PRACTICAL INDICATIONS FOR GALVANISM 

In treating a case of Bell's palsy do not begin the application 
earlier than from ten days to two weeks following the attack. Ap- 
ply the positive pole to the nape of the neck, the negative being 
applied to the distribution of the peripheral nerve upon the face, 
from 3 to 6 millimetres being used. So with other local palsies 
where " reaction of degeneration " has been found, such as in 
wasting of muscles from infantile palsy, or in brachial and sciatic 
neurites. 

In the tachycardia of Graves's disease, the application of from 
4 to 6 millimetres of current for as many minutes will often act 
favourably in slowing cardiac action, through stimulation of the 



98 TEEATISE ON KEEVOUS DISEASES 

vagi. Place the negative pole over the apex and the positive over 
the carotids b}^ an extension of the positive pole in Y -shape. 

The removal of superfluous hair can be accomplished through 
a galvanic current, as follows; by cathode application to the root 
of the hair within its follicle : For this purpose, a very fine flexible 
steel needle securely fastened in a plain insulated 'holder is passed 
down along the hair to be removed from its follicle. There should 
be neither resistance nor pain; if there be, the edge of the follicle 
has been struck and the attempt to introduce the needle must be 
repeated. The offending hair is held by means of a small forceps, 
by which it is extracted later. 

The circuit is completed by the patient placing her hand upon 
the wetted sponge anode. The current must be imperceptible, and 
within twenty or thirty seconds of its passage froth appears about 
the needle, and a short while thereafter the hair pops out without 
traction on the forceps. The patient then removes the hand from 
the sponge, and another hair is selected for the same treatment. 
This subject is mentioned in detail since it is a valuable means 
of helping us in the therapeutics of melancholia in sensitive women 
due to excessive hirsute growth. I have seen excellent results in 
the mental disorder where other therapeusis had failed. 

The galvanic is also the current used for the relief of pain, as in 
neuralgia; and the positive pole should be applied to the painful 
part in such cases, the negative pole to be applied to some indif- 
ferent distant part of the body. It should not be administered 
longer than five minutes at one seance. When the current is pass- 
ing and both poles are applied, it is termed " closed,^' and when 
one pole is removed or the circuit broken by the spring attachment 
placed on the negative electrode, it is termed " open." There are 
certain definite relations in reaction of the muscles to the current. 
First, when the current is closed, the negative pole, being placed 
over the biceps muscle — for example, the positive over the dorsal 
spine — there is contraction well seen at the moment of closing. 
When we reverse the pole, the positive being placed over the biceps 
muscle and the negative over the spine, you will see that at closing 
of the current by the attached spring or interrupter the contrac- 
tion of the normal muscle is much less marked at closing. 

" Eeaction of degeneration " is always made with a galvanic 
current; never determined in palsies the results of the cerebral 
disease — i. e., of central origin — but is found in lesions of the 



ELECTRICITY 99 

peripheral neurone, as in disease of the anterior horns of gray 
matter of the cord, neuritis or other degenerative divseases of nerv- 
ous tissues, peripheral to and including the multipolar cells of the 
gra}^ matter of cord or medulla, as indicated above. 

The order of lessening the contraction of muscles with begin- 
ning degeneration of nerves, finally represented in " reaction of 
degeneration," is as follows: 

CaClOAClC 
AC1C<CC1C 
ACIOCCIO AOC. 

The formula AOC>CaOC always obtains, however. 

Euddiness appears at the point of contact of the negative po"": 
upon the skin, as over the biceps muscle, and if the current is made 
strong enough or allowed to pass a few moments, a peculiar ^' ting- 
ling " sensation will arise, and finally an actual " burning," 
which, indeed, can go on to excoriation where the current is al- 
lowed to pass of too great strength. You will find for use in the 
upper extremities an average of 5 to 10 milliamperes is quite 
enough, as shown by the attached milliamperes through its needle 
index. 

REGULATIONS OF THE GALVANIC CURRENT 

The rheostat governs the amount of electricity passing from 
the battery to the body. A convenient movable lever with X. upon 
the index, when pushed far to the right or left, always points to 
the negative pole, and in larger machines the current is obtained 
from a series of galvanic " cells." Therefore we can take the cur- 
rent in different wards of a hospital by a transfer cabinet, or " con- 
verter." For use in private work, we generally carry a galvanic 
battery of 20 to 30 cells. (See illustration.) 

AXIOMS 

A few axioms and termis used in electro-therapeutics it will 
be well to define. The force originating in a current is designated 
as the electro -mot or force. The strength of current used upon the 
body is equal to the electro-motor force plus internal and external 
resistance. Ohm's law is that the strength of the current is equal 
to the electro-motor force divided by the external and internal re- 
sistance. Stabile application of a continuous current is where the 

L.cfC. ' 



100 



TREATISE ON NERVOUS DISEASES 



poles are first applied in one place, then the current turned grad- 
ually on. Labile is where the galvanic or interrupted currents are 
set up first, then the poles placed to the parts to be treated and 
constantly moved from one nodal ^ point to another. 




Fig. 21.— Complete Galvanic Dry-Cell Battery (with milliamperemeter and^ 

rheostat). 

The current that produces the greatest contraction of the mus- 
cles with the least pain is always applied. 

A ''dry" cell is one in which the conducting medium in the 
battery is not a liquid,, and, while convenient, is not to be depended 
upon as is the "wet" cell. 

The sinusoidal current is one that comes in therap'eutics be- 
tween the galvanic and faradic currents. It is a current of greater 
intensity and less in quantity than the galvanic current, and is 
the result of insertion of a series of magnets in the galvanic cur- 
rent. It is used as a stimulating agent in cases of extreme atrophy 
of muscles, etc. 



1 Nodal points are points of constant potential in a muscle. Motor points are points in a muscle 
more irritable than others. 



ELECTRICITY 



101 



FARADIC ELECTRICITY 

The faradie current is the so-called induced or interrupted cur- 
rent, and is generated from a cell in a like manner to the galvanic 
current as described. It is^ however, so modified by the interposi- 
tion ,of a coil of fine iron wires as to change the character of the 
electricity by ^' induction " to great electro-motor force ; but it has 
little chemical power compared to that of the continuous or gal- 
vanic current, because the fact of breaking a current with the in- 
ductive coil changes the manner entirely in its action upon the 
human body. This current is simply used for the exercise or devel- 
opment of muscular tissue because it produces contraction of mus- 
cle. These contractions are either rapid, when the rapid inter- 




FiG. 22. — Combination Dry-Cell Galvanic and Faradic Battery, 



rupter is used, or slow, as when the large lever is placed within 
the current and by magnetization is caused to swing to and fro 
slowly. 

In using this kind of electricity pain is not produced in the 
patient so easily as it can be produced by the galvanic current; at 
least, not of that burning or chemical character, as has been men- 
tioned. In fact, we do not think of using the word qualitative 
in relation to faradie electricity, since quantity of contraction and 
but little or no qualitative symbolism maintain? : so little, indeed, 



102 



TBEATISE OX XERVOrS DISEASES 



that it is noi necessary to tax the memory with the very small 
amount of difference hetween contractions made when the positive 
faradic pole or the negative is placed over the muscle stimulated ; 
since, too, the pole is changed through the fact that the direction of 




Fig. 23.— Complete Electric Cabinet (with dynamo alternator). 

the current is changed with each interruption caused by the act 
of induction itself. 



USES OF FARADIC ELECTRICITY 

The faradic current is used, as has been inferred, for the de- 
velopment of the muscles. The '"'rest treatment." consisting of 
massage, isolation and rest in bed, full feeding and electricity, is 



ELECTRICITY 103 

aided b}^ faradism very much in the efficiency of the fullest treat- 
ment and benefit to the large majority of cases. The application 
of faradism to the human body, as typified in this course of treat- 
ment, we shall now indicate. This consists of about forty-five 
minutes' application in the following fashion : The patient should 
be in repose and treated at about midway between the meals, prefer- 
ably in the morning or afternoon or early evening, all depending 
upon the time of giving massage, the two separated widely in the 
waking hours. The room should be at about 75° F. in the ma- 
jority of instances of neurasthenia, or varying with the idiosyn- 
crasy of the case ; the point being, of course, to prevent " catching 
cold.'' Having the patient placed on one side and thoroughly re- 
laxed, the rapid current is applied to the feet by metallic electrodes 
well covered with absorbent cotton. This will not take more than 
five minutes, and will produce an agreeable sensation of tingling 
to the patient, warming the extremities at the same time. Then 
the sloiv interrupter is placed, and the two poles are applied over 
the bellies of the extensor and flexor muscles of the leg alternately, 
producing in each separate group well-marked contractions at the 
breakings of the current. This will take five minutes more. The 
thigh is treated in the same way, producing again as strong con-, 
tractions of the muscle as possible without causing pain, the guid- 
ing principle being never to produce pain in administering any 
form of electricity. The other limb is treated in the same manner, 
the patient being turned on the opposite side and the treated limb 
being wrapped in a blanket for protection. This will have con- 
sumed about twenty-five minutes. The upper extremities are 
treated in like manner, and you will find the current much more 
easily perceived here by the patient. The agreeable sensation given 
to the hand by the rapid current is most soothing, while the con- 
tractions induced in the forearm muscles, then in the arm and 
shoulder girdle musculature will have caused a sense of warmth 
and stimulation to the whole of the members. Now apply the cur- 
rent for about twenty minutes upon the upper members — a shorter 
time than applied to the lower limbs, but quite as efficient, however, 
since the upper extremities and their muscles are much more easily 
manipulated. The blanket being folded across the chest protects 
this part of the anatomy, and while a cover also remains across 
the lower limbs (the patient lying supine), the broad flat muscles 
of the abdominal walls are next treated. Then the patient can be 



104 TREATISE OX XEEVOUS DISEASES 

turned over on the abdonjen, the erector spin^e group of muscles 
are given a few moments' contraction or exercise, when the case 
will have been fully treated. The patient is now well covered, with 
the blanket kept next to the skin, and perfect quiet being insisted 
upon, he is apt to fall off into a delicious slumber. 




Fig. 24.— Static Machine and Complete Series of Electrodes. 

Thus the patient gets objective exercise without calling upon 
his subjective state— i. e., the central nervous system— to furnish 
force from his own vitality, which is neecling the rest. It must 
be remembered we are describing the typical case, and as with mas- 
sage, exceptional instances occur which for some reason in an 
hysterical or excita1)le neurasthenic electricitv will not be well 
borne. It should be stated also that the felicity and facility with 
which the faradic current is applied depend upon the amount of 



HYPNOTISM 105 

practice and experience gained from persistent effort to do the 
thing well. With this ease of execution you will find the time of 
application can he cut down ver}' much, and with the same efficacy 
to the patient. 

The faradic hrush attached to the negative pole to produce irri- 
tation is another tonic method of applying the induced current, 
useful in such sjanptoms as hysterical anaesthesia. The skin should 
be dry when this is employed. 

FRANKLIN OR STATIC ELECTRICITY 

This electricity is generated through friction, as of a revolving 
wheel upon leather or wool. It is a current of very low electro- 
motor force, but v/ith great intensity, and is used simply as a 
stimulant to arouse better circulation, such as in chronic rheuma- 
tism, old cases of hemiplegia, lumbago, and in chronic articular 
disease with joint pains. It is also a most active tonic, and a 
spark passed up and down the spinal column — the patient being 
placed on the insulating stool for three to five minutes — serves 
mightily to awaken nerve energy in one who is neurasthenic or 
in ephemeral nerve-tire from whatever cause. 

Before giving this current especially should the patient be 
warned else he might interpret the snap of the spark as something 
serious, whereas it is so rapid and of such a minimum quantity 
that there is no danger whatever, and, indeed, burning of the 
clothing or even of a piece of paper placed between the poles will 
never occur. You regulate the amount of current to the pleasant 
sensation produced in the patient. This is done by sliding resist- 
ance rods more closely together, thereby lessening the resistance 
which the body itself would otherwise have to perform, and, of 
course, with greater discomfiture. The static breeze is a milder 
form and can be used upon the scalp for neurasthenic, helmet-like 
headache. (See Fig. 24.) 

HYPNOTISM 

By hypnotism (from Gr. liypnos — sleep) we refer to the induced 
sleep or state of sleep produced in a subject by a second person.^ 
It is more easily induced in persons or individuals the subject of 

^ Some authors claim that there is a self -induced hypnotism, but this will 
be found to be the result of suggestion immediate or remote from a second 
person in every instance. 



106 TKEATISE ON NEEVOUS DISEASES 

highly nervous temperaments, or actually suffering from some func- 
tional nervous disease. Some psychologists contend that hypno- 
tism can be induced in the best minds as readily as in those persons 
referred to, but this is not my experience, although I have seen 
a very intelligent man hypnotized after a prolonged effort. In 
medicine, hypnotism should be used entirely as a curative agent. 
The school of Bernheim and Charcot have developed this form of 
therapeutics more than any other; and while there are a number 
of different stages given by certain authorities on this subject, it is 
sufficient to here define only three stages of the hypnotic state: 
(1) That of lethargy, in which the patient's mind is obtunded. 
He breathes easily and the circulation is quiet. In a few moments 
in the typical instance of hypnosis the patient will pass into (2) 
catalepsy, which latter consists of the lethargic state plus muscle 
rigidity, and from this the subject gradually passes into (3) som- 
nolence, when he breathes deeply and is apparently sleeping in a 
relaxed state. These three subdivisions are not accurately defined 
in the majority of subjects, one predominating over the other, 
depending upon the idiosyncrasy of the case. The methods of 
inducing hypnotism are many, but all depend upon the same phe- 
nomena — namely, absorbing the patient's interest entirely in one 
direction, having prepared him by the suggestion that he should 
think of nothing but sleep and at same time try to sleep. The 
holding of revolving mirrors before the eyes or any bright object 
for fixation will be the instrumentality used. The physician, of 
course, must have the bearing of confidence to impress the patient, 
and the subject should be told that nothing will be done save the 
desire to cure the given ailment. It is well to have the person 
in a quiet room and to fix the eyes in a strained position so that 
they soon tire. Thus the conscious mind is held in abeyance and 
the subconscious mind alone predominates, the subject passing 
under the control of the manipulator. It is desirable to place the 
patient in the third stage, if possible, befoi^ attempting sugges- 
tion, although in difficult subjects suggestions for cure may be of 
avail even when the patient does not pass beyond the lethargic 
stage. The suggestion for cure should be made while the patient 
is hypnotized, and for practical success should not be too dogmat- 
ic, as, for example, in case of hysterical palsy. In this way the 
doctor has better control and the patient is not disappointed; 
moreover, the physician will more likely be able to succeed in the 



THE EEST TREATMENT 107 

hypnotism of the subject at another time if he fails in the first at- 
tempt. Indeed, in many patients or subjects that are really suscep- 
tible to hypnotism, it will be found that it must be resorted to at 
different times before suggestion for cure can be pressed upon 
them. The post-hypnotic suggestion, so called, which consists in 
the endeavour to induce in the subject hypnotized the doing of 
certain acts or the producing in them of certain sensations long 
after the hypnotic state — thus, a suggestion that tobacco will be 
unpleasant to the tobacco fiend — is a possibility. 

Hypnotism has a very limited range and should be used as 
a last resort in cases where the ordinary mental influence of the 
physician does not avail. It is especially of value in local hyster- 
ical palsies, either sensory or motor, and is distinctly of less value 
as the functional paralysis is more general. Cases of hysterical 
hemi-ansesthesia I have never seen benefited by its use. 

THE REST TREATMENT 

This method of treatment, devised by S. Weir Mitchell, is of 
especial value in neurasthenia and h3"steria. 

Its essential features are isolation, absolute rest, diet, massage, 
electricity, and the personal influence of a good nurse. 

Isolation from the patient's family and former surroundings 
is essential. The diet, if the digestion is bad, should be entirely 
of milk. Otherwise easily digested solid food may alternate with it. 

Rest must be absolute in severe cases; even sitting up in bed 
should not be allowed. The duration of the treatment should be 
from four to eight weeks. 

The following schedule, as given by Dr. J. K. Mitchell, will 
illustrate the method : 

7 A. M. : Cocoa ; cool sponge-bath, with rough rub and toilet 
for the day. 

8 A. M. : Milk. Breakfast. Eest for one hour. 

10 A. M. : Eight ounces peptonized milk. 

11 A. M. : Massage. (See previous section.) 

12 X. : Milk or soup. Reading aloud by the nurse. 
1.30 p. M. : Dinner. Rest one hour. 

3.30 p. M. : Eight ounces peptonized milk. 
4 P.M.: Electricity (general faradization). 
6 P. M. : Supper, with milk. 



108 TEEATISE ON NEKVOUS DISEASES 

8 p. M. : Eeading aloud by nurse for one-half hour. 

9 p. M. : Light rubbing by nurse with drip-sheet. 

Eight ounces malt extract with meals ; tonic after meals. ^ Eight 
ounces peptonized milk with biscuit at bedtime, and a glass of 
milk during the night, if desired. 

This may be modified in various ways according to the symp- 
toms. If a mild case, the patient may be allowed to sit up for a 
few hours, or even go out for a drive. 

Object of the " Rest Treatment." — Of which rest is the essen- 
tial factor, is (1) to secure repose and time for recuperation from 
exhausted nervous states, and this is assisted by (2) isolation from 
friends and other sources of cause for expenditure of nerve-energy ; 
then comes (3) massage and electricity, both agents to mechan- 
ically exercise the muscles, to hurry the blood and lymph streams 
on, and to stimulate metabolism without using up the patient's 
little reserve force. To use Dr. S. Weir MitchelFs apt phrase, 
" massage and electricity deprive rest of its attendant evils." Im- 
agine any one in health lying abed for twelve weeks or more with- 
out this excellent energizing agent. He would more likely waste 
than gain in nerve or muscle tone, and even if his weight should 
possibly increase during the time, it would be in flabby tissues, 
the majority of which would be only deceptive evanescent fat. Fat 
in itself is a burden, not a gain, to the individual. Better be 
" lean " and hardened, as the athlete or thoroughbred, than to have 
excess of the so-called pannicuhis adiposus. 

ON THE CARE AND TREATMENT IN CONVALES- 
CENCE FROM FUNCTIONAL NERVOUS DISEASE 

There is no department of neurology more neglected than the 
proper understanding, or at least if appreciated the neglect of 
sufficient advice to convalescents from serious disorder of the 
nervous system; and in this place we shall devote especial con- 
sideration to functional diseases, those so considered in the ab- 
sence of accurate scientific data to throw the light of a definite 
pathology upon many cases of them. Therefore those diseases 
to be discussed shall be naturally enouo^h neurasthenia, hys- 
teria, and chorea — the author admitting, however, that there are 
many cases secondary to some physiologic perversion or to an irri- 
tation ; still, as it is always difficult to determine the fons et origo 



TREATMENT IN CONVALESCEXCE 109 

mali, the majority of cases are usually set down in the text-bOoks 
as functional. As it is not intended to be specially scientific as to 
aetiology, and as the resultant disease (whether functional or due 
to primal causes other than the ordinary overwork, mental strain^ 
etc.) is the same, the treatment of convalescents from either essen- 
tial or from secondary neurasthenia would be in large measure 
alike. Dismissing at once this subject of aetiology — not because 
of its lack of importance, for we purpose insisting upon the keep- 
ing clear of all causes for the development of a secondary condition 
in the beginning or at any stage — we shall formulate certain prin- 
ciples to be obeyed in the management of cases where diagnosis 
of the diseases under discussion has been established; in other 
words/the care of the patient after the malady has fully developed 
and has been treated successfully towards the happy issue of cure, 
which latter can be maintained only by the principles that we shall 
attempt to lay down in this contribution. We will include there- 
fore, in this practical treatise, suggestions for the betterment of 
the person who is called by the physician — for the want of a better 
name — " generally nervous,^' the result of previous functional 
nervous disease.- 

Mental Care. — In the first place, these patients must be schooled 
or educated in self-control. This may seem to savour a bit of 
charlatanism; but when the profession learn to better appreciate 
that there is really a psychologic basis, a suggestion, in this form 
of therapeusis, there will be less chance for Christian Science and 
other fads, with more adherence to true medicine, so that the 
proper balance may some day be reached, and the modest medium 
of common sense more generally prevail. Nor will there exist, 
at that happy time, any basis for the rather trite slur at the social 
fabric which " Mr. Dooley '' has recently expressed, in effect, that 
Christian Science believes there is no disease, and physicians be- 
lieve that everything is disease. 

A certain amount of time will be required therefore, by 
the alienist and neurologist, in explaining away, to intelligent 
people, certain fads with which they have become infected; and 
while the task is a hard one, results of treatment will show 
a fair enough proportion of success, and the doctor will at 
least be given credit for making the endeavour to rid society of 
these baneful influences. Of course, if you are dealing with a 
crank, diplomacy will be shown by dropping the subject. x\s it 



110 TEEATISE OX XEEYOUS DISEASES 

has well been expressed by some one^ '^ You can take a crank by the 
hand, but cannot lead him on." With these few words, we shall 
dismiss the somewhat mysterious side of medicine, so essential to 
success, however, and pass to more scientific truths — the care of the 
human body physically, the better understood and more easily ex- 
plained matter. 

Physical Care. — Most patients, after an attack of acute or pro- 
longed functional disease, feeling the burden lessened and cure set 
in, will, in their exhilaration, and from the fact that the nervous 
system does not feel the insult at first, go back to the usual method 
of life — of strain and overwork — with a zeal that will usually pre- 
cipitate disaster if persisted in; so that, as regards rest, the con- 
valescent should be taught responsibility in the care of himself. 
If he refuse to carry out our directions, the result cannot be 
blamed upon his physician. These are they who pass from one 
reputable man to another, without any permanent good results. 
This is only within the bounds of reason, and does not necessarily 
require scientific demonstration, valuable as that may be. It is 
an axiom of nature that rest should follow after the central neu- 
rones have once been depleted, ph3'siologically or pathologically. 
Even in cases of hysteria with full muscular vigour, I doubt if 
overuse of the muscular system will but prevent fullest recovery. 
In the cases of hysterical palsies, it is necessary, however, to en- 
courage exercise to a limited degree in order to give confidence 
to the patient, as well as for development of the wasted muscles. 
Thus, the most desirable forms of exercise during the late, ultimate 
convalescence from neural maladies are in a general way to be 
made different from the exercise obtained by the patient in his 
usual routine of life ; and here again the psychologic element must 
enter prominently as the reason for this betterment. Exercises, 
therefore, that keep the patient away from his usual line of 
thought, or prevent him from thinking about self, are to be en- 
joined. And if the patient can be kept off his limbs, it will be 
more advantageous for rest of the central nervous system, and 
thus recreate that reserve force which has become wanting in them. 
So that rowing, canoeing, horseback-riding will be much more valu- 
able than golfing, tennis-playing, or bowling. 

Adjuncts and Medication.— It is important to treat symptomat- 
ically organs that are disturbed in function during convalescence 
from the diseases under discussion; thus, in cases of gastralgia or 



TREATMEXT IX COXVALESCEXCE 111 

of supersensitiveness of the gastrointestinal tract, it may be neces- 
sary to treat the mucous membrane. In these cases, we have a 
neurosis of the vagi nerves and of the abdominal sympathetic 
system. 

In the case of Mrs. W.. a woman of delicate constitution, aged 
thirty-six, under the writer's care, suffering from essential neuras- 
thenia, the result of society indulgence, one of the most annoying 
features in convalescence was subjective sensation of distress in the 
abdomen. Three years previously, this had assumed a form of 
distinct gastralgia. The use of intestinal antiseptics, as small 
doses of salol, also the addition as a digestant of ox-gall, gr. i, 
and extract of gentian, gr. ^, a half-hour after meals, acted effi- 
caciously, and the patient has gone on to complete cure after a 
prolonged treatment which had not entirely restored her equilib- 
rium when she left for the country. It was this little addition 
of a digestant that capped the climax towards cure. She gained 
fifteen pounds in four weeks. 

Another case of Miss P., aged twenty-five, a very intelligent 
young woman, was a most persistent case of neurasthenia, greatly 
benefited by intestinal antiseptic treatment in addition to a semi- 
rest cure. In this case large amounts of indican were found in 
the urine. 

Another adjuvant in the treatment was high flushings of the 
colon with a solution of lime-water, and it was interesting to see 
a facial acne disappear with the general improvement of the case, 
and especially after resort to the measures mentioned. The reten- 
tion of toxines in the system is undoubtedly a factor in preventing 
many cases of neurasthenia from reaching fullest health : until 
this detail is carried out, the patient wilLnever become well. The 
writer has seen good results in the treatment even of epilepsy by 
means of antiseptics and flushing the intestine with copiously pure 
water between meals. 

Apropos of this subject, the reader is also referred to an article 
by Morris de Eleury in the Bulletin General de Therapeutique, 
Xovember 23, 1900, in which he gives tables showing, in the Ex- 
cretion of ITrine in Xeurasthenia, the amounts of uric acid, urea, 
and phosphates: the earthy phosphates being greatly in excess 
of sodium and potassium. Indican or skatol was found 73 
times out of 100. The coefficient of oxidation was decreased 
55 times out of 100; the increased acidity of the urine and density 



112 TREATISE OK KERVOUS DISEASES 

of the same, 59 times out of 100 cases recorded. Such data as this 
goes to prove the wide-spread disturbance of metabolism in func- 
tional disease. An investigation ^ by the writer has been for deter- 
mining the same conditioiis. 

The treatment, therefore, will more and more depend upon the 
exact knowledge obtained through the physiologic and pathologic 
study of chemistry, it seems to us, for the permanent cure and 
prevention of these ubiquitous diseases; so that while the gastro- 
intestinal tracts the great laboratory of the body, may be second- 
arily affected in neurasthenia, it is essential to treat the symptom 
as well as the fujidamental condition of nerve-cell exhaustion. 
Frequently peptonization of the large quantities of milk taken will 
be of great value in aiding hypernutrition. The skilled use of 
massage is also a measure which will help metabolism in the muscle 
itself, as well as by mechanically forcing on waste products and 
giving vigour to the circulation; for frequently, in these cases, 
the cardio-vascular system is not doing the physiologic dut}^ re- 
quired. 

Excitement of an unusual nature should be strictly prohibited 
in cases of neurasthenia, and this is especially more important in 
the convalescent from chorea. In the latter disease, even pleasur- 
able excitement may be sufficient to cause irritation, and relapse to 
follow. A very marked instance of this condition of things was 
shown in the case of a minister's daughter, aged fourteen, coming 
under my care on November 6, 1900. She had been continuously 
in choreic movements since January, 1900, having been somewhat 
improved in health by September, 1900, when she started to school 
and had a relapse. The slightest pleasures she enjoyed were suffi- 
cient to make her worse. The child was anaemic, complained of 
vague pains in the lower extremities, and was greatly emaciated. 
The use of Blaud's pill, 5 grs., three times a day, of salt sponge- 
baths at night and of arsenic in small doses, and the insistence 
upon the use of woollen underclothing, by July 3, 1901, eight 
months after beginning treatment, brought her to a timely cure 
— to health she had not known for many years. This case is de- 
tailed to show that chorea is no slight disease to deal with, and 
that it should be studied in all of its aspects as to hygiene for the 
patient, if health is to be restored. It may have been that previous 

^ Uric Acid Excretion in Neurasthenia, Transactions of the College of 
Physicians of Philadelphia, vol. xxii, 1900. 



TREATMENT IN CONVALESCENCE 113 

failures in this case were due to a lack of hygienic precautions 
being insisted upon to the parents, who were perfectly willing and 
did carry them out when so forcibly directed, of which they are 
the greatest appreciators to-day. 

CLIMATOLOGY OF NERVOUS DISEASE 

Under climatology come temperature, humidity, winds, purity 
of air, rarefaction of air, sunlight, electricity, soil, woodlands, and 
social surroundings. The therapeutic climate is one which im- 
proves functional activity or increases the resisting power of the 
organism. Climatology, the medical geography of climate, is to 
climatotherapy what materia medica is to therapeutics. The main 
use of climatotherapy is as an adjuvant to ordinary therapeutics. 
Dr. A. Manquat, of Nice, has given the best authoritative study 
of this important subject.^ 

Difficult though it be, certain fundamental facts must surely 
exist and are being gradually worked out. The writer has made 
some studies ^ upon the climatology of neurasthenia, finding that 
one of high' winds or in an altitude above 2,000 feet, or in damp, 
low countries, is bad for this disease. Moderately high altitude, 
2,000 feet, is, on the contrary, desirable in sclerotic cord diseases, 
since decreased atmospheric pressure favours better circulation. 

More elemental facts to be recalled are that air at sea and at 
high levels is purest. The temperature above sea-level diminishes 
about 1° F. for every 300 to 400 feet, and is less the drier the 
air. Temperature of air varies less near sea-level, and is less in 
the southern hemisphere. The higher the elevation and the colder 
the air the less moisture it contains. Ozone and electric influences 
of mountain countries are apt to irritate nervous people. Weber 
speaks of marine, low-level inland and high-level inland as the 
great divisions of climate. Warm marine climates and sea voyages 
on calm water are best, perhaps, of all for neurasthenics. High 
climates are best for anaemic cases. The Riviera, low Colorado, 
Canada (in summer) are the most desirable climates for the nerv- 
ous invalid. Inland Maine is also of value. 

' Bulletin medicale, November 27 and December 14, 18, 1901, and January 
1 and 8, 1902. 

^ Climatology of Neurasthenia, Medical News, January, 1901, and Nervous 
Cardiac Symptoms due to High Altitudes, February 14, 1903. 



CHAPTER V 
SYMPTOMATIC DISORDERS 

VERTIGO 

Synonyms: Dizziness, Giddiness, etc. 

By vertigo we understand a disturbance of consciousness, char- 
acterized by a feeling of objects moving (objective vertigo) or of 
a sensation of the person moving, which is termed subjective ver- 
tigo. 

Causes. — The causes of vertigo may be classed somewhat like 
those of headache: (1) Hasmic — anaemia, hyperaemia, etc.; (2) 
toxic — tobacco, alcohol, lead, etc.; (3) arterial sclerosis; (4) acous- 
tic nerve irritation; (5) neuroses — neurasthenia, epilepsy, etc.; 
(6) reflex — ocular, gastric, organic, as organic brain disease; (7)- 
mechanical causes, as swinging, sea-sickness, car sickness. 

Symptoms. — They usually come on suddenly, and last but for 
a few moments. The patient may have the sensation of rising 
or sinking, or objects moving or whirling about (the objective 
form), or the patient himself may feel as though he was revolving 
or to rise and fall (subjective form). There is a sense of alarm 
and a feeling of faintness. Cerebration is disturbed and ideas are 
confused. There may be nausea or vomiting. The patient usually 
totters, and sometimes falls. It may be due to certain lesions of 
the cerebellum and its peduncles, or of the labyrinth of the inter- 
nal ear. It is then usually associated with forced movements. 
The characteristic of vertigo is that it is relieved when the patient 
lies supine. This is the opposite condition in a case of headache. 
(See section on Headache.) 

A large proportion of the vertigoes met with are due to dis- 
ease or irritation of the eighth nerve and its centres. The more 
common cause is a lesion of the labyrinth of the internal ear. 
Vertigo, therefore, is a symptomatic disease. If the blood is debil- 
itated, angemia, or if the patient is plethoric, hypergemia, the symp- 
toms of this affection will come hand in hand with the vertigo. 
114 



SYMPTOMATIC DISORDERS 115 

If the disease be due to arterial sclerosis, which produces a local- 
ized anaemia of the brain, the vertigo will then be associated with 
symptoms of cerebral arterial sclerosis. In some, of these cases 
the kidneys are also affected in the process, and we have the symp- 
tomatology of the red-granular kidney, low specific gravity to the 
urine, decrease in the quantity of urea, etc. If associated with 
neuroses, we have the characteristic symptoms of these several 
affections, such as neurasthenia and hysteria, and the vertigo will 
be apt to present exacerbations comniiensurate with the paroxysms 
of the several diseases, or else the vertigo will be more exaggerated 
sequent to aggression of symptoms of the neuroses mentioned. The 
reflex vertigoes will be associated with the organ that is particu- 
larly involved, as the cause of the irritation. Thus a patient suf- 
fering with astigmatism would complain of the eyes, as a rule, but 
not always so, however. The patient with gastric vertigo would 
have gastric attacks or crises. This is more usual in persons about 
middle life. From organic brain disease the reflex vertigo would 
be associated with some pathologic process going on within the 
cranium. The mechanical causes giving rise to vertigo will be 
easily enough determined by the careful observation of the physi- 
cian. Toxic vertigoes are associated with sepsis in different parts 
of the body, or are from drug poisons, such as tea, lead, coffee, etc. 
Auto-intoxications will be associated frequently with the finding of 
indican in the urine; the gouty with secretion of urea, uric acid, 
and alloxuric bodies, and other end products. 

Diagnosis. — The differential diagnosis of vertigo would depend, 
as above indicated, by noting the symptoms of the several diseases 
associated with, preceding, or following the attack. 

Prognosis. — This depends entirely upon its duration and the 
ability to cure the cause. Haemic and toxic vertigoes will usually 
recover if treated early. Those cases due to arterial sclerosis are 
very bad as to the prognosis. Those due to neuroses are also 
difficult cases to manage. The mechanical vertigoes will subside 
with abatement of the cause. 

Treatment. — Quietude is an essential. This will depend en- 
tirely upon the cause. If there be anemia, haematics should be 
administered, such as tincture of chloride of iron and Blaud's 
pill. If due to plethora, venesections, or better, wet cupping or 
the application of the natural leech, will often prove of great 
value. The use of potassium iodide as an alterative and sorbefa- 



116 TREATISE OX XERVOUS DISEASES 

cieiit^ continued in small doses, often produce marked ameliora- 
tion of the symptoms on any case. Nitroglycerin y^-g- gr. t. i. d., 
or spt. of gionoin, 5-minim doses. If ear disease is present, the 
case should he referred to a competent aurist for the proper diag- 
nosis and treatment of the condition. 

The patient should lie supine during an attack. 

INSOMNIA 

This is sometimes called sleeplessness, and is given to those 
conditions of insufficient or restless sleep or to the entire absence 
of sleep for a long time. Certain persons present idiosyncrasies 
as to the amount of sleep required. Xapoleon required hut a few 
hours out of twenty-four. It is said that some people can go with- 
out sleep for indefinite periods, as long as two or three weeks at a 
time, cases being on record of much longer times of the waking 
state, inflicted as a punishment. Eight hours in twenty-four is 
the average for an adult; children require more. 

Causes. — The male sex suffers more than the female sex, no 
doubt due to emplojmient being more of a mental nature in men 
than in the majority of women. Labouring classes are less liable 
to insomnia than those engaged in business or professional pur- 
suits. It is frequently hereditary, no other exciting cause existing 
that is known. It is also seen in certain diseases, such as gout and 
lithaemia, etc. Quite probably it is the result of auto-intoxication, 
the absorption of certain ptomaines or leucomaines, or other dia- 
thetic by-products. Diseases of the cardio-vascular S3'stem may 
lead to insomnia. Poisons may also cause insomnia, such as are 
seen as the result of syphilis, malaria, chronic nephritis, or other 
infectious diseases, lead-poisoning, etc. Those cases which are 
not due to definite lesions are designated functional ; for instance, 
the insomnia of neurasthenia and vaso-motor disorders. 

The time of the sleeplessness varies. Some persons cannot 
sleep during the early hours of the night, and others will awaken 
at a certain time and cannot sleep thereafter. In children it is 
accompanied by much mental and physical disturbance, such as 
dreams, physical or mental excitement. 

The patient is also seen to be irritable from the loss of sleep, 
and this is much more exaggerated in children than in adults. 
Insomnia from neurasthenia usually presents a tumult of thoughts 



SYMPTOMATIC DISORDERS 117 

passing through tlie mind which seem to prevent sound sleep; 
or in them sh^op is very superficial, the patient being aroused 
very easily and frequently imagining that he was partially awake 
during the sleeping period. In this form the patient wakes easily 
and 'afterward feels " draggy/' as though he had had no rest at 
all, and frequently describing the sensation as though he was 
weaker after his limited sleep than before the time when he went 
to rest. In the insomnia of adult insane, there is a still greater 
degree of restlessness. A symptom described by Weir Mitchell fre- 
quently occurring just at the prcedormium is a sudden jerking 
of the bod}^, which arouses he patient just when he was passing 
into a doze. 

Pathology. — This seems to be as yet unknown. It is very likely, 
however, that there is a variation in the calibre of the cerebral 
vessels, causing congestion, due to a weakness of the sympathetic 
system. " Retraction " of the cerebral neurones is also given as 
the " neurone theory of sleep." The pathology of symptomatic in- 
somnia, due to organic disease, would be the pathology of the 
disease in question, as a chronic meningitis, cerebritis, gummata, 
etc. 

Treatment of essential insomnia, so called, lies often in the 
treatment of some general disorder, such as hysteria or neuras- 
thenia. If anaemia, lithaemia, uraemia, or other toxic influences 
exist, they must be removed by the proper remedies for these con- 
ditions. Measures for the relief of the symptoms themselves should 
be adopted, and the patient should get rid of worry as much as 
possible. The use of the constant cold douche to the spine from 
three to five minutes, followed by cold sponging of the body, usu- 
ally produces sufficient reaction to cause a dilatation of the su- 
perficial blood-vessels to induce sleep. The overuse of the hot 
bath is to be decried, since it is apt to weaken the patient, and 
by not producing proper reaction to the surface will allow stag- 
nation of the blood in the meninges. The methods of counting 
or other monotonous occupations will sometimes avail, but these 
are of doubtful efficacy, and should be substituted by other forms 
of occupation. The patient should live in the open air as much 
as possible, and particularly in those localities where dry winds 
prevail and at low altitudes. • Drugs used with caution are bro- 
mides, 10 to 15 grains at bedtime or in combination with chloral 
hydrate, 5 to 10 grains, being cautious to guard the heart with 



118 TEEATISE OX XERYOUS DISEASES 

the use of the latter drug. Trional or sulphonal in 15-grain doses 
in hot milk are the best hypnotics. Hyoscyamus in some instances 
is efficacious. Paraldehyde in drachm doses is a valuable hypnotic 
in insomnia due to alcoholism. Camphor, opium, and the evanes- 
cent drugs, as asafoetida, musk, valerian, etc., are all of value in 
hysterical or neurasthenic insomnia. The use of massage and 
Swedish movements at bedtime are measures that are of great 
value, and particularly the effleurage to the face, thus producing a 
quiet effect through reflex action upon the cerebral cortex. 

NEURALGIA 

This is a t3'pe of pain, shooting in character, occurring along 
the course of a sensory nerve, and functional or toxic in nature. 
There are different varieties of this disease, as follows : trigeminal, 
brachial, sciatic, cervical, intercostal, anterior crural, and visceral, 
etc. Reminiscent neuralgia is that which exists after the cause 
has disappeared. It is at times a monohysterical sign. 

Causes. — Common predisposing causes of this condition are 
early adult life, debility, and hereditary predisposition. The char- 
acter of the pain is sharp and shooting in nature, and frequently 
accompanied by tender spots or points over the exit of the nerve 
from a canal (points of Yalleix), although firm pressure over the 
site of the pain will generally give relief. Yaso-motor and secre- 
tory symptoms may occur. 

Facial Neuralgia. — This is induced by cold exhausted condi- 
tions, and is more frequent in the female sex. It has a distinct 
hereditary tendency. The attacks come on at irregular intervals, 
and involve some one or all the three branches of the fifth nerve. 
The pain is sharp-shooting and paroxysmal. 

Treatment. — This consists principally in the protection of the 
surface and the building up of the system, and for the attack the 
use of analgesics, such as phenacetine and antipyrine. The appli- 
cation of warmth to this in the shape of hot water is sometimes 
a means of relief. The use of cod-liver oil, to build up the S3^stem, 
is a valuable adjunct. Aconitia in yi^ -grain doses is of value. 

Tic Douloureux. — This is a most severe form of facial neu- 
ralgia. 

Symptoms. — A sense of numbness, occurring at the site of the 
branch particularly affected, such as the superior maxillary branch, 
finally followed by dull pain, which soon amounts to acute suffering 



SYMPTOMATIC DISOKDEKS 119 

and rather spasmodic iu nature. In the height of the paroxysm 
the patient is in most exquisite suffering, all the branches of the 
fifth nerve being involved. There may be an ephemeral blindness, 
occurring on the side affected. An attack may last from one to 
two hours to twelve hours or even longer. There may also be 
spasm of the facial muscles. The teeth may be very sensitive 
during or after an attack, and sometimes the pain is so localized 
in the teeth or maxillae that the physician or patient may think 
the tooth is the real seat of the disorder, and for this reason many 
teeth are extracted. The frequency of paroxysms varies from once 
a day to once in several weeks, although some cases may go much 
longer. The exciting causes are worry, overwork, exposure to 
draughts, and dampness. 

Diagnosis. — This lies between this disease and migraine, but the 
character of the pain in the two diseases is essentially different, 
and there is not the nausea and vomiting in the trifacial neuralgia 
as in sick headache. The type of pain which is induced by these 
paroxysms and may become chronic or hallucinatory is an exam- 
ple of reminiscent pain, and is a psychic phenomenon purely. 

'Prognosis. — As a rule it is unfavourable. The patient seldom 
gets entirely well after the disease has once been established. 
Some few cases, however, have been cured when treated in their 
incipiency. 

PatJtoIogy. — This consists in subacute neuritis in the branches 
of the fifth nerve, also degeneration of the Gasserian ganglion in 
the worst cases. 

Treatment. — In the treatment, examination of the teeth should 
be a point in order to determine reflex points of irritation. Any 
other irritants about the face -should be eradicated. For the par- 
oxysms of pain, the use of analgesics is indicated, as phenacetine 
combined with caffeine. Galvanism by placing the positive pole 
over the painful area is of service. At times a hypodermic injec- 
tion of morphine will have to be given in order to relieve, although 
this should be in a guarded measure in the treatment. Cannabis 
indica is of some value in these cases when given in prolonged 
small dosage. ^Cod-liver oil and tonics, with the use of iron in 
anaemic cases, is very good treatment. Excision of the Gasserian 
ganglion is to be had as a dernier ressort. 

Intercostal Neuralgia. — This is a form in which the pain is 
limited to the distribution of the intercostal nerves. This is some- 



120 TEEATISE ON NERVOUS DISEASES 

times designated pleurodynia. The pain is worse on movement 
of the side or in the ordinary respiration of the patient, so that 
it is frequently called " a stitch in the side.'^ 

Prognosis. — This is favourable. 

Treatment. — This is the same as for other forms of neuralgia, 
plus the strapping of the side of the chest; or the use of counter- 
irritation by means of the use of the actual cautery will sometimes 
give relief. The so-called herpes zoster is the type in which we 
have a neuritis of the intercostal nerves and frequently an erup- 
tion, vesicular in character, along the course of the nerve. This 
disease seems to be in some cases infectious in nature, and is more 
frequently seen in childhood than in adult life,, it also very fre- 
quently being bilateral. 

The treatment of herpes zoster does not differ from that of 
other forms of neuralgia except that protection to the eruption 
of the part should be insured. This can best be done by means of 
oiled silk or cotton batting. 

Sciatic Neuralgia. — This is neuralgia of the sciatic nerve. 
Some doubt the existence of pain in the sciatic nerve area with- 
out there being an active inflammatory lesion present. There are 
a certain number of cases in which the increased reactions and 
exquisite neuralgic pain, without tenderness on pressure, would 
lead one to suppose they were not inflammatory. 

Prognosis. — This is, as a rule, good. 

Treatment consists of splinting the lower extremity during 
the exacerbation of the disease. Tlie use of the ordinary reme- 
dies mentioned above is indicated. The majority of persistent 
cases that do not respond to the treatment outlined are really of 
an inflammatory nature — a neuritis. (See section on Neuritis.) 

Anterior Crural Neuralgia. — This is a neuralgia existing along 
the course of the anterior crural nerve, as its name would indicate. 
The pain shoots down through the outer upper aspect of the thigh 
towards the inner side of the knee. This sometimes is induced 
by lesions, as indeed is sciatic neuralgia in the pelvis, , such as 
tumour, growths of bone. It is also designated parcestlietic 
neuralgia when the distress is of a burning sensation. 

Prognosis. — This is good if the original cause can be relieved 
or cured, as through removal of a tumour. 

Treatment. — This is the same as for the other forms of neu- 
ralgia, except that nerve stretching is singularly often curative. 



SYMPTOMATIC DISOKDEKS 121 

Visceral Neuralgia. — Gastralgia is one of the most important 
forms. This consists of pain localized to the epigastric region. 
It bears no relation to the ingestion of foods particularly, ex- 
cepting that it is at times relieved by taking of food. The dis- 
ease is due to the irritation of the gastric filaments of the pneumo- 
gastric nerve. 

Prognosis. — This depends upon the condition of the system. 
If metabolism improves the patient usually recovers. 

Treatment consists in the application of heat to the epigas- 
trium, the use of Fowler's solution in gradually ascending doses, 
given after meals (gtt. iij to x t. d.) and treatment of existent neu- 
rasthenia. The use of repeated blistering I have seen cure. 

Neuralgia of Heart. — This consists in painful paroxysms about 
the praecordia. and accompanied by a subjective feeling of pending 
death. There is a sense of constriction, as though the heart was 
grasped in a vice. The lips become pale, the pain is most in- 
tense in the praecordia, of a constricting character, and frequently 
shoots down the left upper extremity. The patient becomes cold 
and clammy, and lies, through both fear and inability to move 
on account of the pain, in a position of fixity of the entire muscu- 
lature until the passing of the spell, which may last from three to 
four minutes to an hour. The patient after the attack is greatly 
weakened, and it is some hours before the sense of fear and the 
pain subsides. Angina pectoris recurs without definite cause, 
although exercise may induce an attack. 

Pathology. — Sclerosis at the orifices of the coronary arteries^ 
with narrowing and fatty change has been found. 

Prognosis. — This is absolutely unfavourable. 

Treatment consists in the use of amyl nitrate inhalations dur- 
ing an attack, nitroglycerin over continuous periods, and the relief 
of arterial sclerosis, if present, by the use of potassium iodide. 
Such patients should live a quiet life, never indulging in over- 
eating or in stimulation. ^lental strain should be avoided, since 
this is one of the patent causes. In the most serious attacks hypo- 
dermic injections of morphine niay be necessary to relieve the 
pain. 

HEADACHE 

This is a condition of pain in the head. It is due to irritation 
of the fifth nerve branches. The characteristic of headache is that 



122 TREATISE OX XERVOUS DISEASES 

it is usually made worse when the patient lies down — i. e., when 
the head is lowered, with the exception of anasmic headaches. 

Cawses. — Overwork, malaria, and other infectious diseases, 
poisonings from without, such as tea and various drugs; poisons 
from within, due to disturbance of metabolism, such as in gout 
and rheumatism, ansemia, and in diseases of the meninges. Final- 
ly, headaches are due to organic diseases of the brain, its mem- 
branes, or overlying structures. Some types of headache are : 

Boring, often described as though a nail were driven into the 
vertex, the so-called lavus of hysteria. 

Shooting or neuralgic headache, which is paroxysmal and ex- 
tremely painful. 

Constriction or helmet-like headache, characteristic of neuras- 
thenia, consists in the sensation of constriction about the scalp 
with vague pain through the top of the head. 

Finally, we have another type of headache, which is confined 
to one side of the head, and is called migraine or' megrim or hemi- 
crania. 

J. C. Wilson gives as causes of headache : 

1. Reflex Irritation — viz., ocular (eye-strain), nasal, pharyn- 
geal, auditory, deca3'ed teeth, reproductive organs (especially fe- 
male), thoracic and abdominal viscera. 

2. Toxaemic. — A. Infections, as acute infectious diseases; ma- 
laria. 

B. Incomplete or perverted pJiysiologic-cliemical processes, or 
the defective elimination of waste, as uraemia, diabetes, gout, 
lithaemia, rheumatism, gastro-hepatic derangements, constipation. 

C. Action of drugs and poisons, (a) Acute: nitrites, quinine, 
opium, alcohol, carbon dioxide, etc. (h) Chronic: lead, tobacco, 
alcohol, opium, tea, coffee. 

3. Circulatory Disturbances. — A. Passive congestion, as by pos- 
ture ; tight clothing about the neck ; pressure on veins by tumours. 

B. Active liypermmia, from excessive physical or mental strain; 
early stage of acute meningitis. 

C. Anaemia, following loss of blood or the idiopathic anaemias, 
especially chlorosis. 

MIGRAINE (Sick headache, megrim) 

Migraine is a type of headache which is so distinctive in its 
phenomena as to warrant special discussion. There is a hereditary 



SYMPTOMATIC DISOKDEKS 123 

predisposition very strongly manifest in this disease. First, direct 
hereditary predisposition to the disease itself is transmitted, sec- 
ond, where epilepsy or some other form of neurosis exists in the 
ancestry. The characteristic features are a periodic discharge of 
sensory impulse from the sensory nerves, producing pain. The 
attack itself is ushered in by hallucinations of sight, frequently 
accompanied by fortification lines, which are subjective phenom- 
ena of divergent lines appearing before the eye of the patient. 
Hemianopsia may develop. The pain is usually first manifest in 
the first division of the fifth nerve, and the pain is limited to one 
side of the head as a rule; hence the name of hemicrania. Soon 
after the onset of pain there is nausea and vomiting, the patient 
becoming very sick at the stomach and the pain reaching extreme 
intensity in from one to three hours, sometimes associated with 
a spasm of the muscles on the affected side of the head. The at- 
tack itself lasts from six to eight hours, when the pain gradually 
subsides, leaving the patient in a weakened condition, from which 
it takes him some days to recover full vigour. There is never 
loss of consciousness during the attack, but at times the exhaus- 
tion so closely simulates an abeyance of the mental state that 
epilepsy is with difficulty differentiated from migraine, some au- 
thors claiming that there is a direct relation between the two dis- 
eases. The attack of migraine comes on periodically, and the pa- 
tient may have recurrences once a week or once a month, and in the 
female at the menstrual epoch, or less frequently. The attacks 
seem to be induced by overeating, auto-intoxication, and infectious 
diseases, such as malaria, etc. 

Prognosis. — This is very indefinite. A guardedly good prog- 
nosis can be made in cases where there is not a history of direct 
heredity and in those of good constitution. 

Pathology. — This has not as yet been definitely determined. 
So far as we know, it is a functional disorder,' consisting of peri- 
odic discharge from the sensory cortical neurones, as already men- 
tioned. 

Treatment. — This consists of measures between the attacks and 
during the attacks. The emunctories should be kept in good con- 
dition, the liver and kidneys active. Any diathetic diseases should 
be treated, such as rheumatism, gout, etc. Carlsbad salts or Eo- 
chelle salts are of value to keep the bowels in a soluble condition 
and for the elimination of toxines. Salol, in 2-grain doses t. i. d., 



124 TREATISE ON NERA^OUS DISEASES 

is of value here. For the attack itself, phenacetine is a valuable 
remedy, given in 5-grain doses, repeated three to four times each 
da}^, and if not effective can be substituted by other analgesic drugs, 
such as antipyrine. The use of tincture of cannabis indica is of 
value in some cases, and should be given in small doses, 3 drops 
t. i. d., gradually increased to the physiological limit. In the worst 
attacks hypodermic injection of morphine may have to be resorted 
to, but this must be guarded, else the drug habit may be brought 
about. 

MENIERE'S DISEASE 

This is a persistent neurosis in which vertigo is one of the most 
important symptoms. There is also irritation or disease of the 
eighth nerve or its centres. The inner ear is usually affected in the 
labyrinth. Deafness is progressive from the first. 

Symptoms. — These are of the most exaggerated type of vertigo 
where other causes are excluded, excepting disease resident in the 
internal ear and where vertigo is associated with extreme nausea 
and attacks of syncope. In this form of vertigo, too, the pro- 
gressive deafness and tinnitus aurium accompanied by forced 
movements, staggering gait, or absolute inability to walk, due to 
the dizziness in the worst cases, each time the patient arises from 
the horizontal position, are all diagnostic. The course of the dis- 
ease is downward from the very first, the patient usually failing in 
general health on account of the extreme distress and inability to 
retain food. Deafness becomes profound as the disease progresses, 
and when complete deafness is present the vertigo ceases on ac- 
count of the destruction of the auditory centres of equilibrium 
which have been irritated. 

Diagnosis. — This is not difficult if the above points in symp- 
tomatology are carefully remembered. 

Prognosis is guarded even in cases where the deafness is only 
slight and the disease not too far advanced. Usually the deaf- 
ness becomes absolute when vertigo ceases and the patient is much 
better in general health. 

Treatment. — The treatment indicated above for vertigo is em- 
ployed. A drug which is harmful in the ordinary cases of vertigo, 
but is of value in these cases, is quinine. This is given in small 
doses and then increased until cinchonism results, the drug then 
being withheld for a time and renewed at intervals in fairly large 



SYMPTOMATIC Di.SORDEKS 125 

physiological doses. Opium has been recommended in this disease, 
but this should be used guardedly on account of the danger of 
the drug habit. Hydrobromic acid in the form of a syrup, given 
30 drops a day, or the usual bromide salts in moderate doses, or 
salicylate of soda, 5-grain doses, t. i. d., will be of great service 
in these cases. Sinkler recommends ergot. Hirt recommends 
hypodermics of 10 drops of a 2-per-cent solution of pilocarpine. 
Bromides given in large doses (gr. xl, t. i. d.) have been recom- 
mended. 



CHAPTEE VI 
CRANIAL NERVES 

DISEASES OF THE CRANIAL NERVES 

Olfactory. — This nerve may be affected either by irritative or 
destructive lesions. If the former, such as a tnmour pressing on a 
nerve, it may produce besides the symptoms of the growth liyper- 
osmia. Destructive lesions, as continued pressure of the tumour 
or a neuritis of the nerve filaments, would produce anosmia. Per- 
version of the sense of smell, or parosmia, may be a symptom in 
certain progressive diseases of the olfactory nerves or centres. A 
fracture at the base of the skull may be the cause of anosmia, as 
in a case of a woman seen under my care, where there were no 
other symptoms, and in which an injury seems to have been the 
exciting cause. A case reported by S. Weir Mitchell in his Clin- 
ical Lessons on Nervous Diseases, I have also had the pleasure 
of studying, but in addition to this the woman had hysterical stig- 
mata, including amblyopia and disturbance of the sense of taste. 

Diagnosis and Prognosis. — Disease of the olfactory nerve can- 
not be confused with other diseases, since the specificity of the 
condition is clear. The prognosis would depend largely upon the 
lesion discovered and the possibility of regeneration of the nerve in 
these cases. * . 

Treatment consists in treating the cause. 

Optic. — Affections of this nerve consist of functional amblyo- 
pias and organic diseases, such as choked disk, optic neuritis, etc. 

Optic neuritis occurs in 85 per cent of the brain tumours, so 
that diseases of this nerve can be expected in that proportion in 
cases of brain tumour, and when found would be suspicious of 
the presence of a neoplasm within the cranial cavity. Atrophy 
of the optic nerve is either primary or secondary. The sclerotic 
diseases frequently have as a symptom atrophy of the optic nerve, 
123 



CRANIAL NERVES 127 

such as in tabes; and secondary atrophy of the nerve would be 
that sequent upon neuritis, usually preceded by choked disk. 
Hemianopsia is a neurologic symptom, and is more frequently due 
to lesions in the tracts, usually unilateral. When the lesion is well 
back of the chiasm (as far as the primary optic centres), the centre 
for contraction of the pupil when light is thrown upon the retina 
is wanting, hence Wernicke's pupillary inaction will be found. If 
the lesion causing hemianopsia is back of the thalamus, the centre 
not therefore destroyed, the Werniche's sign will not be present. 
The test for this important sign is made as follows : Throw a ray 
of light in a darkened room upon the unsound side of the retina ; 
it will not cause the normal contraction of the pupil for the reason 
given; whereas, as soon as the ray of light impinges on the sound 
side of the retina, contraction of the pupil takes place immediately. 
This is the most delicate test, and has been by some writers thought 
impossible to make accurately, although admitting the scientific 
relation of the symptom to the disorder in question. 

Other forms of hemianopsia are hiiiasal, which condition is 
extremely rare, and is due to a double lesion, involving the outer 
fibres of the tracts as they pass to become a component of the optic 
nerves proper on their respective sides. Bitemporal hemianopsia is 
usually the result of a tumour of the pituitary body, which de- 
stroys the anterior fibres of the commissure, passing to the inner 
side of the retina. Hence in acromegaly where the pituitary is 
frequently found diseased that the symptom of bitemporal hemia- 
nopsia may exist. Hemianopsia may also be horizontal, as where a 
tumour or other lesion affects one-half of the nerve or tract above 
or below, destroying it or its function, and producing blindness in 
the upper or lower fields of vision. This, however, is a very rare 
affection (for illustration, see Fig. 19). 

Hemiopia should be explained here, since it refers to the side 
of the retina blinded. For instance, right lateral hemiopia implies 
disease of the retina on the right side, whereas it means in terms 
of hemianopsia blindness in the left field. 

Treatment. — Treatment of the diseases of the optic nerve con- 
sists in treating the underlying conditions when bearing upon 
nervous diseases. Optic atrophy seems sometimes to be benefitted 
by the use of electricity, passing 6 or 8 milliamperes of the gal- 
vanic current through the head, with the negative pole at the occi- 
put and positive placed over the eyelids. This done two or three 



128 TREATISE ON" NERVOUS DISEASES 

times a week (a three to five minutes application) will often be of 
some benefit to the patient. Conditions of errors of refraction, 
muscnlar unbalance, etc., are entirely in the province of the oph- 
thalmologist, who should be consulted in all such cases. A dis- 
ease in one of the optic nerves and closely allied to diseases of the 
nervous system is cataract, since this insidious blinding of a person 
may lead to general nervousness and even melancholia, which 
should be looked after in all such cases with the idea for relief 
through extraction of the cataract. 

Oculomotor. — Paresis of the third nerve produces nystagmus, 
protrusion of the eyeball, and ptosis. There are two types of pa- 
ralysis of the third nerve — one in 
which the external muscles alone 
are involved in the palsy and to 
which the name external oplitlial- 
moplegia is applied, and second, 
where the internal muscles of the 
eyeball are paralyzed, designated 
internal ophthalmoplegia. 

The causes are basilar men- 
ingitis, syphilis, and neuritis of the 
nerve and trauma as in some cases 
of fracture of the base of the 
skull. If the cause of the lesion is 
recent tertiary syphilis, the prog- 
nosis can be considered fairly good. 

Fig. 25.— Congenital Nystagmus If it is an evidence of parasyphi- 
(mother also affected). ,.,.., ... ,-, , , , • 

litic intoxication, the treatment is 
not of much avail. Instances of basilar meningitis are guarded as 
to the prognosis, since no one can tell how much destruction will 
result in incipient paresis of the nerve from the pressure that is 
produced. 

Diagnosis. — This could not be confounded with any other con- 
dition, if the movements of the eyeball in relation to the anatom- 
ical and physiological condition of the eye are carefully studied, 
external strabismus being the most prominent symptom besides 
the ophthalmoplegia already mentioned above. 

Treatment. — This consists in treating the original aetiological 
factor. Potassium iodide in doses of 10 to 30 or 100 grains 




CRANIAL NERVES 129 

t. i. d. is usually one of the most valuable treatments if ])ersisted 
ill early in all acute cases. Later, after the absorption of the exu- 
date has taken place, the use of strychnine, if generally indicated. 
If fracture of the skull occurred and the nerve was severed, there 
cannot be any hope for amelioration, since operation could not 
reach the site of the trouble without being the cause of death in 
itself. 

Patheticus. — The palsy of this nerve is due to either neuritis, 
meningitis, or trauma. It causes paralysis of the superior oblique 
muscle; the eye is permitted to turn upward and inward. If the 
condition is dependent upon a neurological lesion, as indicated 
above, treatment would come under that of the neurologist, and 
would consist in the administration of iodides, and later strych- 
nine. The ophthalmologist, as in all diseases of special nerves of 
the eye, should be consulted in order to determine any special 
treatment of the eye affection itself. Isolated palsy of the fourth 
nerve is rare. 

Trifacial. — This is one of the most important nerves in the 
affections of same, from a neurological point of view ; since diseases 
of this particular nerve produce more suffering and occur more 
frequently in neurotic individuals than in any other nerve. The 
cortical centre of this nerve is in the anterior part of Broca^s 
convolution, the lower centre being in the floor of the fourth ven- 
tricle. The lesions producing diseases of the fifth nerve are either 
central or peripheral; excepting in some few cases of cortical dis- 
eases where the lesion is supranuclear. There would not be the 
reaction of degeneration in any degree of destruction of this cen- 
tre, whereas, if peripheral parts of this nerve are involved, degen- 
eration of the branches would occur. This is a distinctive point 
in regard to all the cranial nerves, and must be carefully studied in 
making diagnosis of a given case. Xeuralgia of the fifth nerve is 
the most common disease affecting it. Tic douloureux has been 
mentioned under the head of separated diseases (see Xeuralgia. p. 
117). The simple neuralgia of the fifth nerve would be looked for 
in the different branches, acccording to the site of the disease, which 
has already been mentioned under the proper heading (see p. 117). 
It should be especially noticed in diseases of the inferior maxil- 
lary branch, it having a motor fibre as well as motor symptoms. 

Abducens. — Paralysis of the sixth nerve produces internal stra- 
bismus. This is frequently due to neuritis, not an unusual lesion. 



130 



TEEATISE OX XERYOFS DISEASES 



The treatment would be for the neuritis, and further, the case 
should be referred to the ophthalmologist for an operation upon 
the muscles affected if degeneration has occurred. 

Facial. — This is affected from supranuclear or infranuclear 
disease. In disease of the cortical centre, which lies in the lower 
Eolandic region, there will be primary facial, spasm and secondary 
paralysis without degeneration. Here the lesion is generally 
unilateral, with the spasm or paralysis of the muscles opposite; 

the corrugator super- 
cilii muscle not being 
affected. Xuclear le- 
sions are generally 
bilateral, usually 
haemorrhage or gum-' 
mata involving the 
floor of the fourth 
ventricle. The symp- 
toms would be pri- 
marily spasm of the 
muscles, and, finally, 
paralysis with wast- 
ing and reaction of 
degeneration. The 

peripheral lesions of 
the seventh nerve, 
which produce symp- 
toms of seventh-nerve 
disease, are, first, the 
i n t m c ra nia I ; second, 
intra-osseous ', and 
third, extra-osseous or extra-cranial. The lesions anywhere along 
the tract indicated in 90 per cent of cases are unilateral. They are 
all termed peripheral lesions, since they are not in the centre itself. 
And the paralysis is designated BeJVs palsy. The extra-osseous 
form of peripheral disease is frequently excited by exposure to cold 
and draughts (neuritis), or, as in rare cases, due to trauma. 
Such a case the author has reported in a girl where a pipe stem 
entered immediately below the helix of the ear, where it lay buried. 
The onset of symptoms in tlie so-called idiopathic cases is, as 




Fig. 26.— Fa-Cial Palsy, Left Side, 

Showing secondary spasm same side, and inability 

to close left eye. 



I 



CRAXIAL NERVES 131 

a rule, sudden, the patient perhaps waking in the morning and 
finding the face drawn to the well side. The wrinkles have disap- 
peared from the paralyzed side, the month is drawn towards the 
(Fig. 26) opposite side, and the patient is unable to wrinkle the 
brow as well on the affected side, saliva dribbles from the mouth; 
there will be inability to maintain the bolus of food between the 
teeth, and also some difficulty in deglutition. The patient may 
also complain of a sense of paresthesia or numbness on the affected 
side, but there is rarely anaesthesia, in which case the neuritis has 
involved the fifth-nerve branches as well. No disturbance of the 
sense of taste exists. The duration of this type is, on the average, 
from six weeks to three months, and depending upon the amount 
of neuritis and destruction of the nerve-fibres will recovery take 
place completely, perhaps in 50 per cent of the cases fully. The 
intra-osseous portion of the nerve is involved in some of the so- 
called idiopathic cases of Bell's palsy, but is much more often 
affected when the patient gives a previous history of otitis media; 
although this might be the predisposing cause to the extracranial 
form in rare cases. But with the history of ear disease the disturb- 
ance of the sense of taste should be looked for, and will also be fre- 
quently found. Taste will be absent or lessened on the anterior 
two-thirds of the tongue on the affected side in such cases, due to 
catching of the chorda-tympani nerve as it passes out through the 
hiatus Fallopii. The testing for deafness should also not be for- 
gotten, and this would be an important point in determining the 
site of the lesion, since if aerial induction of the tuning-fork is bet- 
ter through the external auditory meatus than when the fork is ap- 
plied to the temporal bone, the deafness is due to internal ear dis- 
ease; whereas if the conduction is better through the bone than 
by the external auditory meatus, the disease causing the deafness 
and the disturbance of taste is resident in the middle ear. Intra- 
cranial disease is associated with deafness or vertigo, the latter 
being a prominent symptom where the semicircular canals are in- 
volved, and deafness where the vestibular portion is the original 
seat of disease. In any case the degeneration of the seventh nerve 
will be found after the tenth day. Prognosis is uncertain. 

Treatment. — In any form of Bell's palsy the treatment of the 
underlying cause is of prime importance, while the prognosis will 
be good in proportion as this cause is determined and can be suc- 
cessfully eradicated; thus, if a meningitis can be controlled early, 
9 



132 TEEATISE OX NEEVOXJS DISEASES 

very likely the patient will recover the full use of this cranial motor 
nerve. Cases due to internal or to middle-ear disease are more 
serious, since the exciting or predisposing cause is the difficult 
condition to remedy. Such a case should be referred early to an 
aurist for proper treatment. Idiopathic cases are best treated by 
applying a blister back of the ear, keeping the patient quiet, adminis- 
tering a purge and carefully searching for any other cause. The 
use of potassium iodide should be had early, and in fairly large 
dosage (from 10 to 15 grains t. i. d.), over a continuous period of 
two to four weeks, when the dose should be gradually lessened. 
A smaller dosage should then be continued for a fortnight, and 
finally the patient put under the tonic influence of strychnine, g^ 
of a grain t. i. d. The use of galvanism should be instituted by the 
tenth day or second week after the onset of the disease. (See 
Electricity, p. 97.) This is the most valuable agent in the success- 
ful treatment of BelFs palsy. 

Auditory. — Disease of the eighth nerve proper consists of tin- 
nitus aurium, due to irritation of this nerve; and deafness, due 
to destruction of the nerve-trunk or its centre. Certain forms of 
paralysis of the seventh nerve, as shown in the preceding para- 
graphs, may complicate, but they need not be rehearsed here. 

Prognosis of eighth-nerve disease depends upon the nature of 
the disease within the temporal bone or whether the nerve or its 
centre is involved; in the latter treatment would be of little or 
no avail, whereas in peripheral trouble, as in middle and external 
ear disease probably much relief or cure by an experienced aurist 
may be brought about. A disease in which the eighth nerve is 
particularly involved is caled Meniere s disease. (See Symptom- 
atic Disorders). 

Glosso-pharyngeal. — The glosso-pharyngeal nerve supplies 
motor and sensory fibres to the pharynx, the larynx, back part of 
the tongue, and sends a branch (Jacobson's nerve) to the middle 
ear. It is also one of the special sense nerves of taste. (The 
chorda tympani supplies the anterior two-thirds of the tongue.) 

Disease of this nerve would produce, if irritated, an increase 
of sensibility in the pharynx and hypergeusia, whereas the de- 
struction of the nerve would produce loss of sensibility, with 
ageusia, on the posterior third of the tongue. Disease of this 
nerve is usually of central origin, and the prognosis and treatment 
would depend upon the nature of the setiological factor of the 



CRAXIAL NERVES 133 

primary disease. Usually in disease of the niiitli nerve ameliora- 
tion is doubtful. 

Diagnosis. — This cannot be confused with any other lesions of 
any of the other cranial nerves, when one remembers the anatom- 
ical distribution of same and its function. Treatmpnt is of avail 
only as the cause can be got rid of. 

Pneumog^astric. — This nerve has its origin behind the olivary 
body of the oblongata superficially, and has its deep origin in the 
floor of the fourth ventricle in close conjunction with the centre 
of the glosso-pharyngeal nerve. It supplies the sensory and motor 
fibres; through the auricular branch, passing to supply sensation to 
the external ear, and a pharyngeal branch supplying motion to the 
pharynx. There are also the lar3'ngeal branches, of which the 
superior supplies sensation to the lar3'nx and. motion to the crico- 
thyreoid mAiscles. The inferior or recurrent branch is entirely 
motor, and supplies the intrinsic muscles of the larynx, excepting 
the crico-thyreoid. Then there are also the cardiac fibres, the 
pulmonary and sensory, the oesophageal, and gastric motor fibres. 
Disease of this nerve, therefore, produces wide symptomatolog)^, 
varying from the absence of sensation to the external ear to paral- 
ysis of the pharyngeal muscles, oesophageal, stomach, and lar3^ngeal 
muscles, and even paralvsis of the heart ; so that in the majority of 
cases of disease of this centre or nerve itself death results from 
heart failure before any other special symptoms could come to the 
attention of the physician. Many vague symptoms in the thoracic 
cavity are due to a neur.itis of the various branches of this nerve. 
As a rule, diagnosis is not made until the final symptoms develop 
and the patient is carried off by heart failure. The treatment 
would consist in eliminating causes, such as intoxications or men- 
ingitis or polioencephalitis. Strychnine may be of service. 

Spinal-accessory. — This nerve has its superficial origin from 
behind the olivary body, and its deep origin below that of the 
tenth nerve, in the floor of the fourth ventricle, making its exit 
through the jugular foramen and supphdng motion to the sterno- 
mastoid muscle, and it also gives motor branches to the tenth nerve. 
Disease of this nerve is usually of an irritative nature, due to func- 
tional disturbances of the centre, resulting in spasmodic wr3^-neck 
(Fig. 27) or torticollis. In this affection, which usually has its 
onset in early childhood, and is sometimes due to rheumatic taint 
or to catchinof cold, drawins: of the head forward and towards the 



134 



TREATISE 0^ NERVOUS DISEASES 



affected side occurs, the chin being pushed to the opposite side. It 
is paroxysmal, although there is a persistent tonic contraction of 

the muscles. If the tra- 
pezius is also affected, 
there will be elevation 
of the shoulder of the 
affected side. It is a very 
chronic disease, and may 
last for years. No defi- 
nite pathology has as yet 
been discovered in the 
majority of cases. Some 
are distinctly hysterical, 
as proved by the fact 
that mental therapeutics 
often cure the condition. 
If it occurs in early 
childhood, it may deform 
'the chest and neck of 
the patient so much that 
the deformity is a very 
important disability. 

Pi'og no sis. ^This is 
therefore very dubious. 
Treatment. — Both medical and surgical measures are to be re- 
ferred to ; medical in the administration of antispasmodics, such 
as tincture of gelsemium or conium, gtt. v, t. i. d. Surgical, which 
consists in the excision of the nerve in whole or in part. Some 
surgeons, as Keen, of Philadelphia, recommend the excision of the 
cervical-spinal sensory roots. This I have seen cure one patient. 
Others have been operated on with the reappearance of the de- 
formity. The patient should have a change of environment, and 
he should live in quietude. Proper gymnastics and chest expan- 
sion exercises are especially necessary in young persons. Appa- 
ratus is occasionally of service in relieving contractures. 

Hypoglossal. — The cortical centres are in the lower part of the 
central convolutions. This nerve has its superficial origin in the 
front part of the oblongata and the deep origin in the floor of the 
fourth ventricle, and passes out through the anterior condyloid 
foramen. It is entirely motor, supplying the muscles of the 




Fig. 27. — Showing attitude in Spasmodic Tor- 
ticolliso 



CEAXIAL XERVES 



135 




tongue, excepting the palcitoglossus, mylo-hyoid, and stylo-hyoid. 
The descend ens noni branch communicates with the second and 
third cervical by the so-called communicans noni nerve. Disease 
of this nerve consists in paralysis in the majority of cases; irrita- 
tive lesions seldom, at 
least, giving symptoms. 
The cause of destruction 
of the nerve is either cen- 
tral or peripheral — i. e., 
is either supranuclear, 
nuclear, or infranuclear. 
If central, it is unilateral. 
If nuclear, it may occur as 
a symptom in bulbar pa- 
ralysis, as well as in local- 
ized- minute apoplexies. 

Usually the cause of 
palsy is neuritis, specific 
in origin, in which case 
it is apt to be unilateral, 
the symptomatology being 
paralysis of one side of 
the tongue, fibrillary con- 
tractions, and atrophy. 
The base of the tongue is 
elevated and the tongue 

protrudes towards the palsied side (Fig. 28). Diagnosis of iso- 
lated lesion is made by excluding apoplexy or other paralyses due 
to a very extensive central lesion, and in excluding neuritis from 
other parts of the body. Atrophy occurs in nuclear or infranuclear 
lesions. 

Treatment. — This depends entirely upon the cause, central le- 
sions and chronic specific disease usually causing permanent dis- 
ability. Neuritis from traumatip causes would be more apt to be 
relieved by antirheumatics or by surgical interference. Elec- 
tricity does not prove of much avail in such a limited area. The 
use of strychnine is indicated, and tending towards regeneration of 
the nerve itself. Acute specific neuritis is hopeful if full anti- 
luetic mixed treatment is earlv administered. 



/ 



X 



Fig. 28.- 



SUPRANUCLEAK PaLSY OF THE RiGHT 

Hypoglossal Kerve, 
Showing tongue deviation to palsied side (Phila- 
delphia Hospital). 



CHAPTEE YII 

DISORDERS OF PERIPHERAL NERVES 

DISEASES OF THE PERIPHERAL NERVES 

The peripheral nervous S3^stem consists of twelve pairs of cra- 
nial and thirty-one pairs of spinal nerves, together with their root 
ganglia and terminal sense and special sense organs; also of the 
sympathetic nervons system. The sympathetic system consists of 
the intervertebral and the cranial ganglia and the peripheral gan- 
glia. The latter arise during embryonal life from ganglionic cells 
of the same class as those of the spinal-root ganglia, then later 
migrate to their position in the sympathetic. According to Minot, 
therefore, the peripheral nervous system is composed of peripheral 
motor neurones, peripheral sensory neurones, and peripheral gan- 
glionic neurones. 

Origin of Nerves. — IModern studies have shown that the true 
nature of the nerve-fibre is but a prolongation of the nerve-cell — 
i. e., of the axis C3'linder of the cell. Added to this axis cylinder 
are supportive structures, also those for insulation when the nerve 
is complete. Motor nerve-fibres, therefore, come from motor neu- 
rones and sensory nerve-fibres from sensory neurones or cells. All 
peripheral nerve-fibres of motor nerves have in the cord or brain 
certain motor cells of origin, and these are known as the nuclei 
of origin of these nerves. This is not exactly the same with the 
sensory nerves. All sensory nerve-fibres take their origin from 
nerve-cells in the posterior nerve-ganglia, or else in corresponding 
cranial ganglia, such as the Gasserian, lying upon the cranial 
nerves. The nerve-cells in these ganglia send off a single process, 
which divides in T-fashion, the peripheral branch going out to 
form the sensory fibre, the central branch passing into the cord 
or brain, and ending in a terminal arborization which surrounds 
groups of sensory nerve-cells. Hence, these latter sensory nerve- 
cells are not nuclei of origin, strictly speaking, but are terminal 
136 



DISORDERS OF PERIPHERAL NERVES 137 

nuclei. Therefore, there are no nuclei of origin for sensory nerves 
in the central nervous system, a matter of much importance when 
we come to consider the anatomy of the cranial nerves. 

PATHOLOGY OF THE NERVES 

Hypersemia and anaemia of nerves brings about types of nerve- 
irritation leading to various forms of neuralgia, of parsesthesia, 
and of motor irritation or paresis. These conditions are usually, 
however, secondary, and are but rarely recognized clinically, since 
it cannot always be determined whether an irritated nerve is anaem- 
ic or congested or, indeed, whether the central nervous system 
may not be mainly at fault. 

NEURITIS 

This is an inflammation of the nerves. It consists of inter- 
stitial and parencliymatous neuritis. The interstitial neuritis con- 
sists of inflammation of the connective-tissue elements of the nerve 
— the epineurium and endoneurium. The parenchymatous neu- 
ritis consists of an inflammatory process, being located in the 
parenchyma. It is further divided into local and multiple. In 
the local form of the disease it is frequently of the interstitial 
type, whereas in the multiple form it is apt to be of the proto- 
plasm of the nerve. It is also divided into acute, subacute, and 
chronic. 

Symptoms of acute neuritis are pain along the course of the 
nerve-trunk, tenderness, moderate fever, and lessening of the reflex 
in the parts involved, with perhaps hypsesthesia or anaesthesias, de- 
pending upon the extent of the lesion. After the first few days the 
tenderness may largely subside, the sense of paraesthesia lessen, and 
the condition settle into a more regular course, somewhat below the 
severity of the onset — i. e., with lessened spontaneous pain and 
tenderness. If localized, an active case may terminate within six 
weeks, or, if general neuritis, the acute may be designated to those 
cases continuing a greater length of time. The reaction of degen- 
eration may be found as early as the seventh day of the disease. 

Causes. — Traumatism, poisons from within and without, in- 
fectious diseases, etc. 

Diagnosis would be only between myalgia and neuralgia, in 
which latter case there is no tenderness on pressure, but rather an 



138 TEEATISE OX NERVOUS DISEASES 

alleviation of the pain ; nor does elevation of temperature-, local or 
general, exist in neuralgia. In myalgia the muscle pain would 
be relieved by firm pressure, while in myositis the belly of the 
muscle would be painful to the grasp, but no nerve-trunk tender- 
ness would exist. 

Prognosis is guarded and depends upon general state of health, 
as well as upon the severity and persistence of the cause. 

Subacute neuritis consists of the disease after it has run longer 
than the average duration of six weeks, or when the nature of the 
infection has been very slight from the beginning, and consequently 
the onset gradual. In the subacute type we have a modification 
of all the symptoms; pain and tenderness are much less severe, 
weakness of extremities and muscles less pronounced, both on ac- 
count of the fact that the nerve structure is not disabled function- 
ally and that there is less pain at the time of attempted muscular 
acts. Reaction of degeneration may be pronounced. The fact 
that a case is subacute immediately makes the prognosis more 
guarded, since the name itself implies a chronicity of the condi- 
tion or a predisposition to the inflammation of the nerves in a 
particular case. 

Diagnosis. — It is likely to be mistaken for neuralgia, but may 
be confused with chronic rheumatism, the difference between the 
two being, of course, the lack of localized tenderness along nerve- 
trunks in rheumatic affections. If a rheumatic neuritis exists, 
there will also be found other evidences of the disease (rheuma- 
tism), such as fever, joint or cardiac involvement, with excess of 
urates in the urine. 

Chronic neuritis is that form which persists longer than three 
months, -and is, as a rule, the sequel of the acute or subacute dis- 
ease. The symptoms are much more modified than either of the 
two preceding varieties, although localized atrophy of muscles may 
be much more in evidence; also, reaction of degeneration will 
be more distinctly shown, while the pain and tenderness and anaes- 
thetic areas along the course of the nerve-trunks will be very likely 
slight, but on the other hand, from the prolonged disability and 
muscular atrophy, palsy is much more pronounced, and the re- 
flexes may be entirely abolished, although in some of the chronic 
interstitial types of mild grade I have even seen increase of the 
deep reflexes, as the knee-jerks. When the latter occurs, it can 
be explained by the irritation of the nerve-fibres through inter- 



DISOKDERS OF PERIPHERAL NERVES VV.) 

stitial connective-tissue overgrowth, wliich re-enforces the reflex 
impulse. 

Diagnosis. — The ditBculty lies between it and chronic neuritis 
of rheumatic type. The symptom pain may be confused with the 
pain of cord disease, as in tabes. In tabes we would have other 
evidence of spinal-cord lesion. There would be no tenderness at 
all, while anaesthesia or other sensory changes would not vary 
much from week to week in cord lesions as it may in neuritis. As 
between rheumatism and neuritis, we have given points above 
w^hich need not be repeated here. 

Prognosis. — This depends on the history of alcoholism or the 
use of other poisons, upon the vulnerability of the patient, upon 
the diathetic tendency of the individual towards rheumatism, etc., 
and upon the locality in which he resides, since a low, damp coun- 
try would be particularly bad for this malady. As a rule, patients 
will recover if proper treatment can be administered early. 

Treatment. — The treatment of acute neuritis, M^hether local or 
multiple, has certain fundamental principles to be observed. In 
the first place, rest of the part involved as nearly absolute as possi- 
ble, is a desideratum. The relief of pain is due largely to this 
measure as well as to cure of the inflammation itself, which is thus 
favoured by absolute immobility. A splint is often a useful meas- 
ure for producing this quietude. If the case is one of multiple neu- 
ritis, the patient should be placed in bed; in the acute form, and 
in many cases of subacute and chronic types cure will be had much 
more quickly if this measure is adopted earlier than is at present 
the general practice. For relief of pain in the acute form, local ap- 
plications of lead water and laudanum (25 per cent) are also of 
value; the arm should be protected by means of cotton or heavy 
wool. Particularly if near a joint, the extremity should be splinted. 
Among drugs, the analgesics will do much to control pain, such 
as phenacetine, antipyrine, etc., in 5- to 10-grain doses, as re- 
quired. Finally, hypodermics of morphine may have to be given 
to control this symptom. The use of sodium salicylate is com- 
mended, particularly in those cases of rheumatic origin. Also the 
•employment of potassium iodide as an alterative is of value. In 
chronic cases, with reaction of degeneration, the use of massage and 
galvanic electricity on alternate days are valuable adjuncts after 
the acute pain and tenderness have subsided. In acute cases the 
diet should be limited, but in chronic cases, where the patient has 



140 TREATISE OX XERVOUS DISEASES 

been run down, the use of nutrients is of par excellence, such as 
meats, vegetables, milk, etc.,- and even cod-liver oil, although in 
cases of rheumatic origin the use of proteids should be guarded, 
according to the idiosyncrasy of the individual. The counter-irri- 
tation over the course of a nerve, by means of blistering, or the 
actual cautery after freezing is frequently of value. The use of 
strong tincture of iodine is another irritant I have seen do good 
service. 

Multiple neuritis as well as other forms may be idiopathic, or 
its aetiology may be from sources already mentioned under the gen- 
eral head of neuritis. A better name for the idiopathic form would 
be essential, since this does not imply that there is not a cause, 
even though not discovered. The more frequent causes, however, 
are alcohol and lead and exposure or infectious diseases, as typhoid 
(Fig. 29). This type of the disease pathologically is usually of the 
parenchymatous variety. 

Special Forms of Multiple Neuritis. — In the alcoholic form 
of multiple neuritis there is early toe-drop, some pain along 
the course of the nerves of the legs and arms, loss of knee- 
jerks, which may indeed be absent before the patient complains 
of weakness or pain in the extremities. There is also consid- 
erable wasting of muscles, with reaction of degeneration coming 
on early in the palsy. The patient presents the gait which is 
styled the "steppage gait,"' due to tlie weakness of the anterior 
group of muscles and sequent toe-drop. There will also be found 
to be extreme gastric disorder, as a rule; a gastric catarrh, and 
pains in the abdominal viscera, due to the alcohol irritating the 
mucous membrane of the stomach, with subsequent inflammatory 
condition of the entire gastro-enteric mucous membrane. There 
may or may not be marked wrist-drop in alcoholic neuritis. The 
heart may be affected, the patient suffering from palpitation and 
arhythmia, and in some cases death may result from involvement 
of the vagi nerves or centres. Palsy of the extra-ocular muscles 
may produce a strabismus, diplopia. In some cases atrophy of the 
optic nerve itself ; and blindness may follow due to the extension of 
the inflammation of the optic nerves. The nails often become brit- 
tle and transversely ridged, caused by lack of growth at special 
epochs in the course of the malady. Frequently the patient be- 
comes the subject of a progressive muscular atrophy, the result of 
degeneration of the nerve protoplasm. In alcoholic neuritis pain 



DISORDERS OF PEEIPIIERAL NERVES 



Ul 



is not a prominent symptom (but it is very pronounced in the so- 
called idiopathic cases). The duration of the disease may be from 
six months to several years, the patient recovering at the end of 
this time in the majority of cases under proper treatment. 

In lead multiple neuritis the symptoms are somewhat different 
from those due to alcohol^ inasmuch as wrist-drop is a very distinc- 
tive and early symptom, toe-drop being rather a secondary or late 
phenomenon. In lead neuritis, the onset is more rapid, and fre- 
quently preceded by gastro-intestinal disturbances, such as tor- 
mina, vomiting, or other evidences of lead-poisoning. Another 
point is the 'fact of the blue lines being about the gums. This is 
due to reaction of the lead upon the saliva producing lead sulpho- 
cyanide. The blue line is always at the junction of the teeth and 
gum, but is upon the latter. The blue line, however, does not exist 
when there are no teeth present, it must be remembered, since the 




Fig. 29.— Bed-ridden Case of Multiple Neuritis (post-typhoid infection). 
Showing toe- and wi'ist-drop. 



tartar is not then present to produce the characteristic chemical 
reaction. 

Diphtheritic Multiple Neuritis.^AYiotheT variety of multiple 
neuritis fortunate enough to be given a special place, and yet many 
times overlooked by the general practitioner, is the diphtheritic 
form, which may or may not be associated with the post-diph- 
theritic pharyngeal paralysis. This I have recently seen in the 
case of a doctor who had been a most healthy specimen of man- 
hood, and who four weeks after the onset of severe toxic 
diphtheria developed neuritis. In him the palsy of the throat was 



142 TKEATISE OjST NERVOUS DISEASES 

very slight^, but the universal involvement of nerves seemed to 
show the very profound intoxication of the nervous system. 
In diphtheritic neuritis, the history of diphtheria, or, if the case 
had not been closely observed, simply the story of a sore throat, 
will be the deciding factor, plus the inability early to swallow well 
or the incapacity to lift the soft palate as in saying " Ah ! " 

Arsenical neuritis is also a type of multiple neuritis, and is 
frequently caused by prolonged medication in the use of Fowler's 
solution or of arsenious acid, either due to the patient taking the 
drug for cosmetic effect, or perhaps in the treatment of chorea. 

Diagnosis of arsenical poisoning resulting in neuritis cannot 
be positively made without a previous history of poisoning, since 
there are not sufficient distinctive features to differentiate this. 
The physician should always look to the history of the patient 
sleeping in a room where arsenic has been deposited in wall paper 
prepared by the arsenical process, not a few cases having been 
reported through investigations by Shattuck, of Boston. 

BERI-BERI OR KAKKE 

This is a type of multiple neuritis, particularly endemic in the 
Philippine Islands. It is probably infectious. Some authors claim 
it is caused by CO2 poisoning, others that it is due to diet of fish 
and rice containing fungi: It is associated with oedema, effusion 
into the serous cavities, such as the pericardium, the peritonaeum, 
or into the ventricles of the brain. It is marked by paralytic and 
atrophic disorders, anaesthesia, and lightning-like pains. Death is 
the result of the effusions rather than of the neuritis proper, or 
else to early involvement of the phrenic or vagi nerves. Mental 
disturbances are frequent. 

Prognosis. — This is absolutely bad. 

Treatment of multiple neuritis does not differ in any chronic 
type except in so far as separate causes are determined — namely, 
alcohol, lead, diphtheria, or arsenic. Treatment of the resulting 
neuritis would, at least, be the same in any case. 

In the types mentioned there is the possibility for aid through 
early elimination of the poison. The use of potassium iodide is a 
valuable measure as an eliminant in all cases due to poisoning by 
drugs. The source of infection should he cut off. Besides, the 
patient should take large draughts of water. The persistent use 
of general massage daily, fresh air and sunshine, plus the use of 



» 



DISORDERS OF PERIPHERAL NERVES 143 

cod-liver oil and hvpopliosphites, living in a dry climate away 
from prevailing high winds, will insure success if carried out over 
many months in cases where chronic invalidism has occurred 
from the lack of persistent endeavour in these directions hy either 
the patient or physician. Strychnine should be given in large 
doses in cases of chronic neuritis — 3V to iV being administered 
thrice daily. The use of galvanism is also a valuable measure 
where there is degeneration of nerve tissue. In this case the nega- 
tive pole should be placed over the spine and the positive over the 
atrophied muscles, a constant current being applied to all the 
palsied muscles for several minutes three or four times a week. 
Massage is of great value when administered daily. Alcoholic 
cases must be rigidly guarded against indulgence in the drug, since 
a small amount of alcohol will precipitate inflammation. Auto- 
intoxication from intestinal fermentation should be prevented by 
restricted diet and the use of salol in moderate doses (2 grains 
t.i. d.). 

Erythromelalgia (see frontispiece) is a variety of multiple 
neuritis affecting the dorsal and plantar nerves of the foot. It was 
first described by Weir Mitchell, who gave it the name of a vaso- 
motor neurosis. We have had the pleasure of studying two of 
Mitchell's cases. One was due to a crush injury caused by the fall- 
ing of a heavy stone upon the foot. The case cured through 
stretching of the plantar and by excision of the cutaneous nerves. 
The other case died of a complication of gangrene of the foot fol- 
lowing infection after the operation of excision and stretching of 
the internal saphenous and musculo-spinal nerves, and of stretch- 
ing of the posterior tibial nerve. Histological examination 
showed neuritis, thickening of the middle coat of the vessels of the 
amputated (affected) foot. This obtained in the smallest arteri- 
oles, while the larger vessels were also calcareous. This type of 
neuritis has particular characteristics. When the affected foot is 
pendant it becomes intensely red; a severe burning pain is set up. 
in which the local temperature rises to as much as^° C. higher 
than when the foot is held horizontally. This is the opposite of 
what occurs in a normal extremity, as Mitchell points out in his 
Clinical Lessons on Nervous Diseases, pp. 202, 203. Walking fre- 
quently is so painful as to be almost impossible. Excess of perspi- 
ration may occur when the foot is pendant or is paroxysmally pain- 
ful. Heat aggravates the pain also, while cold relieves it. Local 



144 TREATISE ON NERVOUS DISEASES 

ulceration from profound trophic disturbance follows in bad 
cases. 

Prognosis. — Usually chronic and persistent. Spontaneous cures 
have occurred. 

Treatment consists in rest in bed, local applications of cold, 
protection of the foot by cotton or splints loosely applied. Galvanic 
electricity, the positive pole being placed over the affected part, 
together with effleurage, may afford relief. Stretching and excision 
of nerves are measures to be adopted where relief fails from other 
forms of treatment. The drug habit should be guarded against. 

Recurrent multiple neuritis is a type described by Sherwood, 
Ross, Osier, and others. Certain individuals are susceptible to re- 
current attacks from definite poisons, particularly from alcohol 
and lead. Since it is not necessary for the intoxicant to be again 
taken to produce recurrence of the neuritis, there must be induced 
in such patients a susceptibility. Each recurring attack is likely 
to be more severe than the former. 

Treatment is the same as for other forms of multiple neuritis. 
It is especially dangerous foi; these patients to be exposed to the 
poison originally causing the disease. 

Leprous Neuritis. — The leprous bacilli may cause neuritis. 
Proliferation of the nerve-trunks occurs, nodules are formed, and 
finally the bacilli may disappear. According to Martins and 
Sonza, the spinal cord may become invaded by the bacilli and 
cavities form, especially in the posterior horns and in the gray 
commissure. Sensory symptoms, particularly of anaesthesia, occur, 
especially in large patches on the face, hands, forearms, feet, and 
legs. Through spreading, a very large area may thus become 
ansesthetic. The small muscles of the hand may be wasted, and 
even the bones may become atrophic. There may occur deformi- 
ties of the hands and feet due to atrophy of the parts, followed 
by contractures. The toes, fingers, hands, and feet may even be 
cast off, as in dry gangrene. The neuritis may last many years. 
Syringomyelia of the Morvan type may be simulated in some 
cases through existent dissociation of cutaneous sensation, very 
likely caused by the disease in the gray cord as noted above. 

After-treatment of Neuritis (continued). — In the toxgemic 
state following the acute infections, large doses of iron, as of the 
tincture of the chloride, are of great value. If malaria is present, 
quinine and arsenic are important remedies. The cachexias that 



DISORDERS OF PERIRllEIJAL NKRVKS- U5 

may exist as predisposing causes should be sought for and, if pos- 
sible, remedied. In cancer, tuberculosis, or in pernicious anaemia, 
the measures that cause general improvement will aid in neuritis. 
In bad cases it may be necessary to pass food through the stomach- 
tube. If the heart is at all enfeebled, such cases should be watched 
most anxiously and quietude enjoined. At times a brachial neu- 
ritis will thus end in death suddenly by extension of the neuritis 
through some anomalous branch connected, more directly with the 
vagi or phrenic nerves, or else it may be a reflex inhibition of 
the heart that occurs. 

Contractures and. posture deformities must be very carefully 
guarded against, especially in alcoholic cases. The weight even 
of the bed-clothing must be taken off the toes by means of " hoops '^ 
or other improvised apparatus. At times the use of splints, where 
there is not extreme sensitiveness, will aid much in preventing 
contractures; as about the ankles. Passive movements in full ex- 
tension, and especially in full flexion of the ankle, should be 
used several times a day in the alcoholic type. Heat applied 
will at times do good in relieving pain. We have seen cold occa- 
sionally do good, but for some unknown reason it invariably 
aggravates any form of neuritis of the upper extremities, though 
it may do good, as indicated in sciatic neuritis. 

Hot baths, Turkish and Russian baths, or needle douches, as 
advised by Charcot, may all be employed late in the course of the 
disease. As with the coal-tar derivatives, the use of morphine or 
cocaine should be very guardedly emplo3Td. The bromides and 
chloral combined allay cerebral' irritability and produce sleep more 
safely than any other drugs. Static electricity is of value to awaken 
the circulation and aid metabolism. This and the faradic brush 
will frequently greatly benefit the cutaneous anaesthesias. The pa- 
tient must be encouraged to walk as soon as possible, since the 
muscles gain power by exercise. Tenotomy may be required where 
contractions have occurred. The use of deep kneading about in- 
durated joints caused by disuse and the inflammatory exudate, is 
of great value, especially if associated with a hot bath (180° F.) in 
an alkaline solution (such as of soap), the Turkish bath, or Scotch 
douche. 

SCIATIC NEURITIS 

This has in the past been confused with neuralgia, or sciatica, 
but where tenderness is present neuritis must exist ; and as a rule. 



146 TEEATISE OX XEEVOUS DISEASES 

sciatic disease is neurilic in origin. Sciatic neuritis is a very 
important disease clinically. 

^tiologi/. — The causes are like in other instances of neuritis — 
general and local. It is more frequent after twenty-one years of 
age. Gibron (London Lancet, 1893) says it is eight times as 
common in males as in females, and this is no doubt due to 
greater exposure of men. Hence, exposure to cold and dampness 
is one of the most frequent causes. It is common in puddlers, 
miners, stokers, and cabmen; neurotic, rheumatic, and gouty sub- 
jects are very liable to it. Lead-poisoning favours it. Diabetes, 
S3'philis, typhoid fever, la grippe, and malaria predispose to its 
development. It may follow operations for lithotomy, childbirth, 
or from pelvic disease in women, or aneurysmal pressure. Bony 
thickening of the sciatic notch or gumma, in rare instances, are 
causes of sciatic neuritis. 

Lumbago may precede or complicate (extension by contiguity). 
Compression of the nerve may be a cause, as in sitting a long time 
on a hard bench, as in shoemakers; or it may be a direct 'con- 
tusion of the nerve, as from a blow. Excessive fatigue of the 
legs may precipitate an attack, as in prolonged use of the sewing- 
machine. The pressure of varicose veins may produce it. 

Spinal disease and new growths in the spinal canal may cause 
sciatic neuritis by first affecting the nerve-roots, the vertebral canal, 
or at the cauda equina. 

Symptoms. — Pain. and tenderness along the course of the nerve 
are the principal symptoms. While both of these signs may ex- 
tend throughout the sciatic distribution, they are more intense 
in the upper half of the thigh near the sciatic notch. The tender- 
ness is often extreme, and the patient may be able by this to trace 
the nerve down to the popliteal space. Below the knee the pain is 
likely to follow the external popliteal. The pain is more or less 
constant, and is very wearing upon the patient, especially since 
exacerbations occur mostly at night, keeping the patient awake, 
when physiological resistance of the nervous system is lessened. 
Flexing the thigh well down upon the abdomen, or walking, creates 
added pain very quickly. Partial flexion of thigh and knee, how- 
ever, with extension of ankle (a characteristic position when the 
patient lies abed), will relieve pain through relaxation. The char- 
acteristic gait of semiflexion and limp is due to the same semi- 
flexion. If it be a chronic case, lateral curvature of the spine may 



DISORDERS OF PERIRIIERAL XERVES U7 

develop, the convexity being towards the affected side. This sco- 
liosis, being muscular, disappears on recovery. A lumbar con- 
cave curve and dorsal convex curve of the spine may develop in 
those rarer cases, with spasm on the affected side due to neuritic 
extension to the anterior crural nerve, the sacral plexus, or lumbar 
cord. This is termed homologous sciatic scoliosis, and is likely 
to become permanent, as the sciatic association symptoms are 
chronic and contractures develop which fix the peculiar deformity. 

Particular points of exquisite tenderness in sciatic neuritis are 
designated tefider points of Valleix, such as the gluteal point over 
the sciatic notch, the troclianteric point over the great trochanter, 
the popliteal point at the division of the nerve, and the fibular 
point, where the external popliteal winds around the head of the 
fibula. There may also be a tender point on the dorsum of the 
foot. In addition, in some cases there may be an iliac point about 
the middle of the crest of the ilium, lumhar points just above the 
sacrum, or a patellar point over the patella; points behind the 
malleoli, in the calf, or plantar points in the sole of the foot. 

It is at these points that the patient complains of paroxysms 
of pain occurring in the course of the disease. This pain may 
be boring, burning, tearing, or lancinating in character, which 
tortures the patient to distraction. Using the limb or ^* catching 
cold " will frequently at once precipitate an attack. At times 
the sudden attacks of pain are spontaneous and periodic, as in 
malaria. Cutaneous sensibility is often disturbed. This may be 
of hypercesthesia in the sciatic distribution followed by anaesthesia, 
or the sensitiveness may be confined to the areas of the painful 
points just given. Par^esthesias, such as feelings of formication, 
fulness, pricking, or of heat or cold, may be present. 

Motor symptoms, as a rule, only appear in the grave cases. 
Cramps, violent tremor or spasm of calf muscles may be present 
and increase the pain. The Icnee-jerh is rarely exaggerated; usu- 
ally it is much diminished, and the heel-jerJc may be absent. If 
there is atrophy of muscles fibrillary twitching is often found, and 
there is then palsy or paralysis. In the worst case a severe spasm 
involving the entire limb may be produced, at times creating the 
most profound distress. A slight draught of air or even the sud- 
den touch of clothing may bring on this spasm, so that the limb 
must be well protected from .both. Yaso-motor disturbance may 
cause flushing or, in severer cases, lividity of the limb, or even 
• 10 



148 TREATISE ON NERVOUS DISEASES 

oedema. Usually the sweat is reduced. It may be increased. 
Erythema, acne, perforating ulcer of foot, herpetiform eruptions, 
or scaliness may all be found in some cases. Reaction of degen- 
eration may be elicited in the wasted muscles. In thin people the 
swollen nerve may sometimes be easily palpated. Excess of fat 
may mask the muscular wasting. 

Double sciatic neuritis is rare and is usually the result of pelvic 
or spinal disease, which makes the diagnosis easy. 

Pathology. — Perineuritis and inflammation of the adventitia 
are present. The nerve parenchyma suffers secondarily. The 
nerve is red and tumefied (oedematous). It is therefore distinctly 
interstitial neuritis primarily. 

Diagnosis. — This must be made from neuralgia or muscular 
rheumatism. In the former the pain is fleeting, and there is no 
nerve-trunk tenderness. In muscular rheumatism the pain is dif- 
fuse, and the muscles about are sore to touch. Hip disease is de- 
termined by the joint tenderness and fixation and pain in the region 
of the obturator nerve. Hysteria may be simulated, but is distin- 
guished by the fleeting character of the pain and the emotionalism 
or other stigmata. The pelvic organs and spine should always be 
looked to as a possible source of the inflammation of the nerve. If 
the disease is bilateral it has pretty positively come from within 
the pelvis, as from a growth, or as indicated above. History of 
syphilis, malaria, or of exposure, often tells all. Injection of a 
local anaesthetic may stop pain for a time when it has begun or is 
entirely located in the nerve, not above the notch. 

Prognosis. — In uncomplicated sciatic neuritis the ultimate re- 
sult is good.. If due to spinal disease, the prognosis is to be 
guarded, since cure of the original trouble is doubtful. The aver- 
age case will last several months, but if the part is used the neu- 
ritis may last for months or even years. Relapses are common. 
If the limb is wasted it may take a year to recover full use of the 
'extremity after the pain has subsided. 

Treatment of Sciatic Neuritis. — This is allied to that of treat- 
ment of any local neuritis. Special measures consist of absolute 
rest of the limb, the patient being put to bed. Or a long, well- 
padded splint can be applied from axilla to external malleolus, and 
the heel should be protected by raising it from the bed by a pad over 
the tendo-Achillis. The limb should be thus held in a partially 
flexed position, first having applied a flannel bandage from foot to 



DISORDERS OF PERIPHERAL NERVES 149 

hip for protection and warmth. Diathetic states, as ol' rheumatism 
or gout, must be treated if present. Examination of the urine is 
very important as to determination of this. Counter-irritation by 
means of strong tincture of iodine thrice repeated, or the use of 
a blister, or of the actual cautery of Paquelin, are all of great serv- 
ice. Extremes of heat or cold may do good in . individual cases. 
Thus, ice-bags or hot poultices kept applied along the course of the 
nerve may give great relief to suffering. I have seen sodium sal- 
ic3^1ate, gr. x, every three hours in peppermint water, do good in 
acute cases. Potassium iodide in chronic cases or injection of co- 
caine or atropine down near the nerve may be of much service. 
But other fluids injected into the tissues the writer has not seen 
of any service whatsoever, nor has puncturing the nerve-trunk 
been productive of any relief, and there is some danger of re-exci- 
ting more active inflammation. Pressure upon the nerve, as recom- 
mended by Negro, repeating the bloodless procedure some six times 
every third day, may aid resolution in chronic cases with sheath 
thickening. Massage likewise is only valuable in chronic cases. 
Electricity is of most value when used twice or thrice weekly, the 
positive pole being applied over nerve-trunk and calf (10 to 15 
milliamperes). Faradization may be of service late in the case 
to develop atrophied muscles. Nerve-stretching by the blood- 
less measure of thigh flexion, the knee being extended, or by 
open incision and lifting the limb from the table by a dull hook 
applied around the nerve-trunk, are required in stubborn cases. 
Tumours near or on an inflamed nerve should be excised. Mor- 
phine hypodermically may be required in bad cases for the pain. 
It seems to produce a good effect upon inflammatory tissue. Alka- 
line mineral waters, as the Buffalo lithia or Londonderry lithia, 
or a course of alkaline baths, as at Virginia Hot Springs or at 
Baden abroad, may be of great value. 

TUMOURS OF NERVES 

A. Hyperplasia. 

B. True neuroma; single henign. 

C. False neuroma; multiple benign, or malignant. 

A. Hyperplasia or hypertrophy of nerve-trunks is rare. It is 
usually due, therefore, to increase of the interstitial connective 
tissue. At times there is an increase of fibres and thickening of 
the myelin sheath. 



150 TEEATISE OX XEEVOUS DISEASES 

B. True neuromata are also very rare, and occur most exclu- 
sively on spinal nerves. In some instances there is an increase 
in medullary fibres, in others only an increase of non-medullated 
fibres — i. e., only the axis cylinders and neurolemma increase. 
These tumours m^ay occur single or multiple. Multiple neurom- 
ata are generally, however, neurofibromata. Nerve-fibres massed 
in hyperplastic connective tissue form plexiform neurofibromata. 

True neuromata are usually quite small, measuring several 
centimetres in diameter only, but they may be much smaller or 
larger. They are usually few in number, though there may be 
a local multiplicity of these true neuromata. Gowers has shown 
that in one case 1,000 were present, and this number may be 
exceeded in rare instances. 

C. False Neuromata. — This term is applied to nerve tumours 
intermixed with fibroma, myxoma, glioma, sarcoma, carcinoma, or 
syphiloma, although the first is the most common variety. Gumma 
has only been found in the false neuroma on the intracranial or 
intraspinal nerves. Scirrhous or medullary (rarely the colloid 
type) carcinoma are the varieties found in combination. Leprous 
neuritis sometimes forms neuro-fibromatous swellings. 

Malignant Neuromata. — Some 30 cases of very malignant neu- 
romata have been recorded in the literature. Hereditary influ- 
ence and trauma are the getiologic factors. The great nerve-trunks 
are most frequently affected, such as the medium or sciatic. The 
tumours start from the perineurium, and are at first spindle- 
shaped ; they may grow very large. Sarcomatous cells are the most 
frequent, but myxomatous cells may be found in them, or fibroma- 
tous tissue, or the tumours may be mixed. 

Tuhercula dolorosa are simply false neuromata situated super- 
ficially at the ends of sensory nerves. 

etiology. — A. Heredity generally tends to cause the true mul- 
tiple or plexiform neuromata. B. Diathetic — e. g., tuberculous — 
influences which produce various forms of tumour formations — 
sarcoma, carcinoma, etc. C. Injuries or surgical operations, which 
cause especially the fibroneuromata, as the amputation neuroma, 
forming often the so-called fm/a&?e 'stump. 

Neuromata may be congenital, and are then usually of the 
plexiform type. Multiple neuromata may develop in early life. 
Men are more liable to neuromata than women. 

Symptoms. — Neuromata may not produce symptoms, but the 



DISORDERS OF PERIPHERAL NERVES 151 

most frequent evidences of their presence, besides physical exam- 
ination, are pain and tenderness. Pressure above the tumour over 
the atfected nerve may at times relieve the exacerbations of pain 
probably by obtunding sensation or cutting off the blood supply 
temporarily. Para^sthesia, anaesthesia, paralysis, and reflex spasm 
may be found. I had a case recently of false neuroma upon the 
median nerve where spasm of the biceps muscle was most annoy- 
ing. Some forms of persistent headache are due to multiple neu- 
romata of the sensory fifth. Single neuromata cause symptoms 
more frequently than multiple or plexiform because they are 
points of irritation, as a rule, near the periphery of the nerve; 
and connective tissue contracting in them also aggravates pain, 
the multiple type being purely nerve tissue. Neuroma of the 
splanchnic or vagi nerve may cause most serious symptoms (sudden 
unaccountable deaths are at times due to neuroma of the vagus ) . 

Multiple (true) neuromata may last for 3'ears and cause no 
serious symptoms or inconvenience. Malignant neuromata cause 
such symptoms as always result from irritation or compression 
of a nerve. 

Diagnosis. — The diagnosis is only positively made when palpa- 
tion reveals the tumour. In other cases diagnosis is made by ex- 
clusion. Lipoma over the site of a nerve is the most easily con- 
founded with neuroma. (The liability of lipoma to appear on any 
part of the body should always make this innocent tumour thought 
of in diagnosis of any growth.) True neuromata are often multi- 
ple; the false are usually single. Idiocy, heredity, neuropathic 
constitution would alw^ays favour the disease being true neuroma. 

Treatment is essentially surgical. Internal medication and 
applications are valueless save as the former is towards general 
building up of the constitution to the invasion of disease. Strong 
galvanic currents (descending), mercury, and the iodides in large 
doses may assist in the resorption of exudate about such a growth. 
Excision is the proper treatment if pain or paralysis are prom- 
inent symptoms. The growth may return. 



CHAPTEE VIII 

DISEASES OF OTHER SPIXAL NERVES 

A SINGLE spinal nerve may be injured by disease or trauma, 
or several nerves may be injured by the same local conditions. 
The principal disturbances resulting are those of sensations^ or of 
motor or trophic disorders which manifest themselves within the 
distribution of the nerves involved. (See Fig. 8.) 

The most usual lesions are new growths, division, degenera- 
tion, neuritis (see Chapter YII). When the lesion is irritative, 
the symptoms are of hyper^esthesia, pain, spasms, tremor, spas- 
.ticity, and rarely of hypertrophy. When the lesion is destructive 
from the first or has passed on to the destructive stage, the symp- 
toms produced are such as anaesthesia, palsy or paralysis, of dys- 
trophy, atrophy, or wasting. The above two groups of symptoms 
are not infrequently blended, the result of partial involvement of 
a special nerve or of the sensory-motor fibres being affected to a 
different degree in a mixed nerve. 

Cervical Plexus. — The phrenic nerve arising from the third, 
fourth, and fifth cervical nerves may be impaired in function by 
penetrating wounds of the neck, as by a pistol shot; or by new 
growths, or aneurysm causing pressure upon it. Disease of the 
cervical vertebra, or disease of the spinal meninges, may finally 
affect the nerve-roots or spinal nuclei. Inflammation, primary or 
secondary, from contiguity with seats of inflammation, may be a 
cause. 

Sensory disturbance in disease of the phrenic nerves may simu- 
late the pain of intercostal neuralgia or of rheumatism; but its 
association with the motor symptoms will clear this up. The latter 
will consist of inactivity of the diaphragm, unilateral or bilateral, 
as shown by failure of the abdominal walls to advance with deep 
inspiration. If the lesion is of both phrenic nerves the breathing 
is distinctly of feminine or costal type ; the dyspnoea is extreme. 

The suprascapular nerve, whicli arises from the fourth, fifth, 
and sixth cervical nerves, may be affected singly in dislocations of 
152 



DISEASES OF OTHEK SPI^-AL NERVES 153 

the shoulder. If so, the siipraspinati and infraspiiiati muscles be- 
come atrophied, the scapula being prominent. Also, the external 
rotation of the arm is impeded, with general weakness of the mem- 
ber due to lack of balance at its fulcrum, the shoulder- joint. Wri- 
ting is very difficult for the reason given. There may be an ances- 
thetic area over the outer aspect of the scapula and posterior por- 
tion of the deltoid region. 

The long or posterior thoracic nerve, branching from the fifth 
and sixth cervical nerves and supplying the serratus muscle, is quite 
frequently exposed to mechanical pressure, as from heavy weights 
carried upon the shoulder by expressmen, etc. ; or it may be com- 
pressed by muscular efforts exerted by overhead workers, as plas- 
terers, etc.; or by swinging the arm constantly, as in chopping, 
mowing, or tailoring. For all these reasons men in active early 
life are more frequently affected, and usually on the right side, 
because the majority are " right-handed." The nerve may also be 
affected along with others in the course of spinal disease. 

Symptoms are mostly motor', since it is almost a pure motor 
nerve. These consist of impairment of expansion of the chest on 
the side affected, and of diminished movement of the upper ex- 
tremit}^, as a result of the non-fixation of the scapula. The in- 
trinsic muscles of the arm itself are not weakened. The deformity 
from paralysis of the serratus produces a peculiarly characteristic 
disfigurement. Placing the arm forward causes the posterior bor- 
der of the scapula to widely wing out from the chest, so that a 
,deep recess is formed behind the shoulder-blade. The upper por- 
tion of the scapula also moves outward, and the lower angle ap- 
proaches the spine. Sensory phenomena are but slight, and con- 
sist of pain in the neck and shoulder in case neuritis coexists. 

Prognosis is less favourable than in injury to other spinal 
nerves, even though the disease affecting it is a simple pressure 
neuritis. This may be due to the fact that pressure is usually 
made along a much greater extent than in the case of any other 
nerves that may be so injured. 

The treatment of palsy of the phrenic nerve will be entirely 
confined to treating the cause, since the nerve is inaccessible to 
mechanical stimulation, and this is largely so with palsy of the 
suprascapular or the long thoracic; but galvanism can be em- 
ployed to advantage in some cases by placing the negative pole over 
the digastric region and the positive down the border of the scap- 



154 TEEATISE OX NERVOUS DISEASES 

ula on the affected side. Strychnine, gr. gV to yV three times a 
day, may prove of value. Massage is of most service. 

CERVICO-OCCIPITAL NEURALGIA 

The symptoms of neuralgia of the first four cervical nerves, 
especially of the occipital branch, are caused by exposure to 
draughts, catching cold, rheumatism, etc. Pain here may also be 
due to caries of the cervical vertebrae. It may be associated with 
neuralgia of the fifth nerve and with torticollis. The pain is 
usually located in the occipital and at times in the posterior pari- 
etal region. It may be bilateral. There may exist tenderness of 
the scalp. Tender spots are found (a) in the triangle between 
the trapezius and sterno-cleido-mastoid muscles; (&) at the angle 
of the great occipital between the mastoid process and the spine; 
(c) above the parietal eminence. 

Prognosis is usually good excepting where the disease comes 
on late in life. 

Treatment consists in counter-irritation to the neck and occi- 
put by means of strong tincture of iodine, the fly-blister, or the 
actual cautery. Galvanism with the positive pole of a galvanic 
current placed over the three tender points indicated above is 
of value. A hypodermic injection of morphine, gr. J to gr. -J, 
guarded by atropine, gr. y|o- , may be required during an exacerba- 
tion of pain. Quinine in full doses or sodium salicylate pushed 
to the physiological limit are of value. Arsenious acid is a de- 
sirable alterative in these cases, especiall}^ where anasmia compli- 
cates, when Blaud's pill, gr. v, t. i. d., should be added. 

The Circumflex Nerve. — This nerve arises from the fifth, sixth, 
and seventh cervical nerves, and descends in the posterior cord of 
the brachial plexus. It then branches off, to pass outward under 
the deltoid muscle, and winding around the neck of the humerus is 
distributed to the teres minor and deltoid muscles, also supplying 
the shoulder-joint with trophic influence. It also supplies sensa- 
tion to a chevran-shaped area over the lower two thirds of the 
deltoid. From its exposed position it is often injured in shoulder 
dislocations, in arthritis, or by falls or blows upon the shoulder; 
or by crutch pressure. 

Symptoms of paral3'sis of the circumflex nerve consist of in- 
ability to abduct the arm from the body due to deltoid paralysis, 



DISEASES OF OTHER SPIXAL ^^EEVES 155 

while the palsy of the teres minor is insignificant. Soon the del- 
toid wastes and the shoulder becomes pointed and prominent, with 
the shoulder- joint relaxed from sequent dragging upon its liga- 
ments. The head of the humerus can be felt very readily. Nutri- 
tion of the joint failing, it becomes the seat of neuro-arthritis and 
partial ankylosis. This is ascertained by noting synchronous 
movement of the scapula with arm motion. An initial arthritis 
may likewise spread by continuity to the circumflex nerve and 
injure the deltoid. Anaesthesia over the skin distribution of the 
deltoid, already described, is usually present in circumflex paral- 
ysis. 

Prognosis is guardedly favourable in cases not due to frac- 
ture. 

Treatment consists of blistering, sodium salicylate in rheumatic 
cases, and after the tenth day galvanism, massage, and move- 
ments, kept up for months. 

Paralysis of the infrascapular nerve, which arises from the 
fifth and sixth cervical roots, consists of palsy of the supraspina- 
tus and infraspinatus muscles, which it supplies; but isolated 
paralysis of these muscles is rare, palsy of this nerve usually being 
associated with deltoid palsy from circumflex-nerve disease due to 
dislocation of shoulder- joint, etc. Paralysis of these two muscles 
alone, however, causes loss of pawer of outward rotation of the 
humerus, shown in loss of power of carrying the hand from left to 
right, as in writing. 

Prognosis is also guarded, since it is difficult to determine the 
extent of injury. 

Treatment is exactly similar to that of circumflex palsy, save 
that massage and electricity are applied directly over the muscles 
involved; so that treatment is more available at least. 

The musculo-spiral nerve arises from the posterior brachial 
cord, and winds around the humerus in the musculo-spiral groove 
between the'two heads of the triceps muscle, where it can be sub- 
jected to muscular pressure, external violence, or pressure. It is 
the most frequently diseased nerve in the body, and at the same 
time is the one in which disease is best in its prognosis. 

This nerve supplies all the extensors of the elbow, wrist, and 
fingers; also both supinators, and through its radial branch the 
skin on the .dorsal surface of the thumb and two radial fingers, 
and the posterior radial border of the hand. It furnishes as well 



156 TREATISE ON NEKVOUS DISEASES 

trophic- joint filaments to the carpus and hand. High up it also 
supplies cutaneous branches to the skin in an area extending from 
the wrist in a narrow but widening strip up the forearm, and over 
the outer aspect of the arm as high as the insertion of the deltoid 
muscle. These latter branches are but seldom involved in palsy 
of the circumflex. 

Causes of disease of the circumflex nerve are legion. It may 
be due to lead-poisoning, when the posterior interosseous branch 
("nerve of lead palsy") is most affected, wrist-drop being the 
only prominent symptom in such cases. In palsy of the circum- 
flex from drug-poisoning, it is also interesting to note that the 
supinator longus is not affected. From its exposed position in 
the axilla crutch pressure frequently causes pressure palsy; or it 
may here be due to dislocation of the head of the humerus. Lower 
down the nerve is liable to suffer from blows upon it, by being 
caught in callus or fractures, or by a cord being tied about the arm, 
or even by direct action of the triceps catching the nerve in its 
gras^o, as in extreme muscular exertion. By far the most common 
cause is from pressure by the patient lying on his arm, or when 
it hangs over a chair, he being asleep, in alcoholic poisoning. The 
reason for this is that the alcohol benumbs sensibility and the pa- 
tient is not awakened by the pargesthesia that would occur under 
normal circumstances. Of course, such pressure may occur under 
any form of narcotism. The surgeon must be careful not to have 
pressure upon this nerve, in operations, while the patient is anaes- 
thetized. Hanging pendant when under an anesthetic may also 
produce pressure palsy from the pull made on the nerve. Finally, 
" catching cold " may be the cause of neuritis and palsy of the 
circumflex. 

Symptoms. — Sensory symptoms are slight and at times not 
present when the motor fibres of the nerve are almost completely 
functionless. If present, it would be in the course of the radial 
and cutaneous branches of the musculo-spiral. (See Fig. 32.) 

Motor symptoms are widespread and characteristic. There is 
wrist-drop and inability of all the long extensors of the hand to 
react if the lesion is high up. There is also inability to extend 
the elbow. If the nerve is affected in the musculo-spiral groove, 
the most usual location as stated, the branches to the triceps 
escape and extension of the elbow is not lost. Lesions below the 
lower one third of the humerus do not catch the branch to the 



DISEASES OF OTHER SPINAL NERVES 157 

supinator longus. The position of the hand (Fig. 30) is char- 
acteristic. The fingers can only be extended by the interossei 
muscles, after the iirst phalanges are extended, which latter are 
supplied by the ulnar nerve. The thumb cannot be extended and 
the fingers can be but a very little better, being progressively dimin- 
ished from the index to the little finger. Occasionally, on the 
back of the wrist there develops a synovial tumour due to extreme 
carpal flexion, and in part due to insufficient support of the ex- 
tensor tendons, also to involvement of the articular branches of 
the nerve. This tumour is painless and much exaggerates the 
wrist deformity. The " grasp " is greatly reduced, due to the ex- 
tensor loss and unbalancing of the muscle movements. Muscular 
wasting shows on the dorsal surface of the forearm, and where 
the supinator longus is involved a peculiar flattening of the fore- 
arm is noticed. The tricQps may be somewhat wasted. 

Prognosis is good in the vast majority of cases, cure resulting. 




Fig. 30.— Wrist-Dkop from Musculo-spiral Alcoholic Pressure Palsy. 

Treatment consists in getting rid of the cause, as of alcohol, 
callus, crutch pressure, etc., or of suturing of the nerve if it has 
been severed. Ordinarily the use of a blister over the supposed site 
of lesion is indicated. The arm can be placed in a well-padded 
anterior splint where there is marked wrist-drop. This will tend 
to prevent joint deformity in chronic cases. Massage and fara- 
dism after the fifth day are indicated in compression cases with 
separation of the nerve elements. Strychnine in full doses is the 
drug indicated par excellence. In cases of active neuritis the case 
is to be treated more conservatively as one of local inflammation. 

The ulnar nerve, originating from the lowest cervical and first 
dorsal nerves, and supplying the forearm and ulnar flexor of the 
wrist, the two inner divisions of the deep flexor of the fingers 
and all the small muscles of the hand except those innervated by 



158 TEEATISE ON NEEVOUS DISEASES 

the median, the abductor of the thumb, and one half of the short 
flexor of the thumb, also suppljdng sensation to the ulnar border 
of the hand, including the little finger and half the rin^ finger, 
is when palsied likely to give a wide distribution of symptoms. 

Causes. — Neuritis, idiopathic or from trauma, tumours, pres- 
sure or separation as by a knife or crockery cut. It may be in- 
jured (a) above the elbow, (6) at the elbow, or (c) at the wrist. 

Symptoms. — Sensory symptoms consist of loss of sensation in 
one half of ring and all of little finger, running up the palm and 
back of hand to wrist, where it tapers off. 

Motor symptoms are marked. The wrist cannot be actively 
flexed to the ulnar side, and the thumb is rotated towards the palm 
by the abductor, and cannot be adducted. The fingers lose lateral 
motion. There is overextension of the metacarpophalangeal joints, 
while the unopposed flexors of the second and third are offset by 
strong contraction of these digits towards the palm, making the 
so-called "claw hand.'' This flexion is least marked in the index 
and middle fingers, which do not lose their lumbrical muscles. The 
interosseous spaces are hollowed and the fifth metacarpal bone is 
entirely subcutaneous. The hypothenar eminence disappears, but 
part of the thenar eminence stands out prominently. 

Prognosis is good if the palsy is due to separation as by a knife- 
cut and nerve-suturing is done at once. In cases of fracture of the 
ulna, with compression, good results will only follow early eradica- 
tion of the offending bone or callus. Idiopathic cases of neuritis 
are less promising of cure. 

Treatment consists first in getting rid of the cause if surgery 
will do it, as indicated under prognosis. Acute neuritis should 
be combated along ordinary lines. Massage and galvanism are 
the most valuable adjuncts to the medical treatment, consisting 
of strychnine, the iodides, and general tonic measures. (It is of 
interest here to note the sudden restoration of function, especially 
of sensation, in case of suturing of the nerve after section, thus 
giving a clue to the possibility of nerve force being through some 
such agent as electricity.) 

Median Nerve. — This nerve arises from the inner and outer 
cords of the brachial plexus, and follows the brachial artery to 
the bend of the elbow. It supplies all the flexors except the ulnaris, 
and the ulnar portion of the deep flexor. It also supplies both 
pronators. In the hand it supplies the opponens, abductor, the 



160 TEEATISE OX XERVOUS DISEASES 

short flexor of the thumh, and the first and second luml)ricals. 
These latter, like the interossei, are accessory to flexors of the 
fingers (first joints), and are aids to common extensors for ex- 
tension of the second and third phalanges. The sensory distri- 
bution of the nerve supplies the radial half of the hand on the 
palmar side, and the tips of the index and middle fingers on the 
dorsal aspect. (See Figs. 31 and 32.) 

Cause of Paralysis. — Injury in common with the ulnar and 
musculo-spiral near the axilla may be the cause of paralysis. Stab 
wounds near the wrist are not uncommon sources of palsy, also 
sprains about the wrist, or fractures, as CoUes's. 

Symptoms, Sensory. — These are usually slight, due to the ex- 
tensive distribution of the ulnar and radial nerves about the same 
areas, but would, in complete loss of function, be in the distribu- 
tion already given. Motor: Pronation is destro3'ed. The thumb 
cannot be rolled into the hand or opposed to the fingers. Xone of 
the fingers can be flexed except the ring and little flngers, which 
still act through the ulnar portion of the flexor profundus and 
interossei. The wrist is flexed slightly to the ulnar side through 
the flexor ulnaris. The first joints of the fingers are still able to 
be slightly flexed through the interossei. The hand becomes flat- 
tened because the thenar eminence is atrophied and the thumb lies 
in adduction parallel to the other fingers ("ape hand"). It is 
the same deformity seen in progressive muscular atrophy of spinal 
origin. 

Prognosis is guardedly favourable if the disease has not gone 
more than six weeks without proper treatment. 

Treatment consists in thorough massage, the use of the ascend- 
ing galvanic current, 10 milliamperes daily five minutes; strych- 
nine, gr. -gV t. i. d., and local protection (splinting) and alter- 
atives, as sodium iodide and arsenic. Xerve suture even late as 
six months after nerve severance has been attended with good 
results. 

COMBINED PALSIES OF NERVES OF THE ARM 

The proximity of the brachial plexus to bony prominences of 
clavicle, scapula, and humerus makes it liable to injury as a whole ; 
hence, palsy of its various nerve branches may result. The mus- 
culo-cutaneous, suprascapular, and circumflex may also be af- 
fected secondarily to disease of the fifth and sixth cervical nerves. 



DISEASES OF OTHER SPIXAL NEEVES 161 

from which they arise. Peterson quotes from the Revue Xeurolo- 
gie, December 15, 1900, that forcible dragging of the arm up or 
down may hicerate the anterior nerve-roots. 

Or a neoplasm or injury opposite the sixth cervical vertebra 
may affect both nerves. At this point (between the scaleni mus- 
cles) Erb has found that the circumflex and suprascapular nerves 
can be stimulated by electricity. The muscles involved in such 
a palsy are the spinati, deltoid biceps, and brachialis anticus, while 
the sensory disturbance corresponds to the cutaneous distribution 
of the nerves affected. 

Injuries to the hracliial plexus are usually severe. I have never 
seen a crush invalving the branches recover. As a rule, injuries 
involve all its branches. But single nerves — e. g., the ulnar — may 
be affected ; or the ulnar in association with the nerve of Wrisberg, 
etc., in which case anaesthesia along the entire inner aspect of the 
arm will also accompany the motor palsy. The so-called "birth 
palsies ^' are due to traction on the arm, or to the use of a hook in 
the axilla or to head forceps during delivery; and usually involve 
all the branches — viz., the median, ulnar, and musculo-spiral. A 
fracture of the humerus may injure the musculo-spiral and ulnar 
nerves. The radial and ulnar nerves may be simultaneously in- 
jured in fractures in the forearm or disease at the wrist. In- 
fected wounds of the hand may produce ascending neuritis, which 
may ultimately affect the entire brachial plexus {neuritis mi- 
grans) . 

Pottos or other disease of the vertebrae may affect the brachial 
nerves secondarily, as also may meningitis, particularly the hyper- 
trophic form: or even disease of the cord, as syringom3^elia, may 
do the same thing. 

Prognosis has been indicated. 

Treatment will consist of getting rid of the cause at once if 
degeneration and an ill result shall not follow. The other measures 
to be adopted will be described below. 

Brachial Neuritis. — Gowers compares this with sciatic neuritis. 
The symptoms consist of pain and tenderness in the distribution 
of the branches, particularly when the shoulder is moved, since 
the circumflex is then much disturbed as well as the other nerves, 
though to a less degree. The pain is often mistaken for neuralgia, 
for rheumatism of the shoulder or arm; careful examination will 
eliminate these. Women suffer more frequently than men. The 



162 



TREATISE ON NERVOUS DISEASES 



disease occurs oftener after middle life, especially in gouty or 
rheumatic people. Lumbago or sciatica may also be existent in 
the case. I have seen a needle prick in the finger in two cases 



External Cutaneous 
Genito-Crural 



Anterior Crural 



External.Popliteal 




Ilio-Inguinal 



Long Saphenous 



Fig. 34. 



-Showing the Distribution of the Sensory Nerves of the Skin, 
Anterior Aspect of Trunk and Leg. 



produce most profound brachial neuritis. The entire arm becomes 
wasted and the hand flattened. The muscles as well as the nerves 
are tender, and the slightest movement gives severe shooting pain 
in the arm and neck. Reaction of deoreneration is found. The 



DISEASES OF OTHEE SPIXAL XERVES 163 

reflexes are usually diminished, but as in chronic sciatica may 
rarely be exaggerated. 

The prognosis is most serious as to cure, relapses being com- 
mon in the most favourable cases. 

Treatment consists in rest of mind and body as fundamental 
principles. The lithaemic state must be looked to. Counter- 
irritation along the course of the plexus and nerves by the actual 
cautery affords great relief. Dry heat will often do good. Cold 
usually aggravates. Protection of the arm by a splint or cotton 
wool is a valuable remedial measure. Ascending galvanism is 
of value. Amputation of the arm below the insertion of the del- 
toid is the only treatment for severe laceration of the brachial 
plexus. In this way the incumbrance of a totally palsied arm is 
done away with, to the comfort of the patient. 

NERVES OF THE TRUNK 

These nerves supplied by the thoracic and two upper pairs of 
lumbar nerves are rarely singly involved. Pott's disease may 
affect them, but the loss is slight unless several nerves are affected 
simultaneously. The girdle sense of tabes or neuritic pain of 
vertebral disease are diagnosticated by observing other signs of the 
respective diseases. Herpes zoster may encircle the body, and in 
such cases the symptomatic disorder is significant of serious root 
mischief either due to extension from spond3'litis or to sclerotic 
involvement, as in tabes ; or it may be from direct metastasis from 
a neoplasm. Unilateral herpes is rather characteristic of gastro- 
intestinal disorder only. Wide-spread trunkal herpes is, as a rule, 
due to final disease of the gray matter rather than of the nerves 
themselves. (See Figs. 34 and 35 for cutaneous nerves of trunk.) 

NERVES OF THE LOWER EXTREMITY 

These are not so frequently involved as those of the arm, but 
are subject to special disease through pressure in pelvic growths, and 
in females by pressure upon the sacral plexus during labour. In- 
flammation of pelvic viscera or psoas abscess may affect the plexus. 
(See Figs. 33 and 34 for cutaneous nerves of lower extremities.) 

The external cutaneous branch of the anterior crural nerve 
supplying the outer side of the thigh is very liable to disease. X 
queer condition termed jparcestlietic meralgia, consisting of a sense 
11 



164 



TREATISE ON NERVOUS DISEASES 



of burning (causalgia) in the outer upper aspect of the thigh, is 
found in neurasthenic women, especially when secondary to ovarian 
disease ; probably caused by a reflex reference through irritation of 
this sensor}^ branch. In other cases a neuritis has been set up. 




Fig. 35.— Showing the Distribution of the Sensorj" Nerves of the Skin. 
Posterior Aspect of Trunk (Butler). 

Gout, rheumatism, excesses in tea-drinking, in alcohol or to- 
bacco may cause it, or as a resultant of multiple neuritis this 
peculiar hypergesthesia may continue for months or years. 

Treatment consists in treating the neurasthenia and in nerve- 
stretching, which usually is successful. 

Anterior Crural. — This nerve may be affected {a) within the 
abdomen, when flexion of the thigh on the abdomen is weakened 
because the iliacus muscle is included, and (6) below Poupart's 
ligament. 



DISEASES OF OTHER SPIXAL XERVES 165 

Si/mpfoms flue to cutting off of entire function, are wasting of 
the quadriceps and abolition of the knee-jerk. Aucvfiihefiia will be 
found to extend from the groin to the inner side of the foot. There 
is but a narrow strip of normal sensation remaining, which runs 
down the back of the thigh below the knee, spreads out over the 
external portion of the calf, embracing the foot except on the inner 
aspect. (See Figs. 33, 34, and 36.) 

Prognosis is good if the cause can be eradicated. When due 
to pelvic tumour, it is hopeless; but disease of the internal geni- 
talia, if causative, being eradicated will relieve the secondar}' neu- 
ritis. Idiopathic cases must be treated as neuritis elsewhere. Ap- 
pl3'ing a long external splint is of great service. Galvanism and 
massage are valuable after acute symptoms have abated. 

Obturator Nerve. — This nerve comes from the same source as 
the anterior crural nerve. It supplies the adductors of the thigh, 
also the knee and hip-joints. Hence it is that ^^ referred " pain may 
be to the knee in cases of coxalgia or disease of the knee may be 
referred to the hip of same side. 

Causes. — Prolonged horseback-riding may cause the neuritis, or 
tearing of the muscles by athletes; or a direct trauma may pro- 
duce neuritis of the obturator. 

Symptoms of paralysis of this nerve. Proper adduction of the 
thighs is prevented; there is impaired external rotation of the 
thigh through palsy of the external obturator and pectineus mus- 
cles. Wasting occurs on the inner aspect of the thigh above. Sen- 
sory symptoms consist of knee or hip pain, depending upon whether 
one or both branches are involved. 

Treatment consists of rest, massage, galvanism, and relief of 
pain by anodynes or by hot applications of lead water and 
laudanum, twenty-five per cent. Disease of knee or hip should be 
treated. 

The superior gluteal nerve may be inflamed, and this causes 
palsy of the gluteus minimus and medius and the tensor vagina 
femoris muscles. The symptoms consist of weakness of abduc- 
tion, outward rotation, and circumduction of the thigh. 

The Great Sciatic Nerve. — The size and exposure of this nerve 
and its branches make it more liable to disease than any other 
single nerve of the lower extremity. It supplies the knee flexors, 
which are also partial extensors of the thigh upon the body. It 
also applies all muscles below the knee. (See Figs. 33, 34, and 35.) 



166 TEEATISE ON NERVOUS DISEASES 

Symptoms. — From the peculiar mechanical position of the mus- 
cles palsied in disease of this nerve, the disability to the patient 
is less than that resulting from disease of the anterior crural 
nerve above recited. The paresis of muscles supplying only about 
the large joints of the hip and knee is the explanation of this. 
The leg is carried forward in progression as a " pegleg " similar 
to that of the hemiplegic gait. Wasting is marked. Perforating 
ulcer of foot may follow. Sensory phenomena consist of anaes- 
thesia occupying the narrow strip of the thigh posteriorly and the 
outer aspect of leg and foot described in the last section. 

Disease of the external popliteal or peroneal nerve may be lo- 
cated (a) in the ham or (&) below the knee on the outside of 
neck of the femur. This branch nerve supplies the long extensors 
of the toes, also the peronei muscles. 

Symptoms^ Motor. — Foot-drop with toe-drop follow; and 
equinovarus may result from contraction of the unopposed flex- 
ors. There is much wasting about the fibula and in the anterior 
group of leg muscles. (See also Sciatic Neuritis.) 

The internal popliteal nerve supplies the calf muscles, the long 
flexors of the toes, all the small muscles of the foot save the short 
extensors of the toes. If its branch, the internal plantar, is di- 
vided, there results a paralysis of the short flexor muscles of the 
toes, the plantar muscles of the great toe, except the adductor, 
and the two inner lumbricales. " Hammer-toe '' results from ex- 
tension of first joint and flexion of second joint. Sensory symp- 
toms consist of anaesthesia in the outer plantar surface of half the 
sole, one half o'f the fourth, and all of the fifth toe. (Fig. 36.) 

If the external plantar branch is alone involved, the symptoms 
are loss of power of the muscles of the little toes, the two outer 
lumbricales, all the interossei, and the adductor of the great toe. 
The hammer-toe deformity is found in all the toes. Sensory symp- 
toms then consist of anaesthesia in the outer plantar surface of 
half the sole, one half of the fourth, and all of the fifth toe. 

If the internal popliteal is divided in the popliteal space in 
addition to above symptoms, there is inability to rotate the flexed 
leg, due to palsy of the popliteus muscle ; and also a loss of power 
of extending the foot. Talipes calcaneus may therefore result 
with,, in addition, the arch of the foot becoming exaggerated. 

Morton's Disease, or Metatarsalgia. — I have seen a number of 
cases under the discoverer's care. Dr. Morton considered it due 



Long saphenous 

m 



Anterior 
tibial 




Internal External 
plantar plantar 



External plantar 
(Br. post, tibial) 




Internal plantar 
(Br. post, tibial) 



Anterior 
tibial 



Long 
saphenous 




Internal plantar 



External saphenous 



External plantar 




Long saphenous 



Blusculo-cutaneoua 
(Br. ext. popUteal) 



Posterior tibial 
Anterior tibial 



Internal plantar 



Fig. 36.— Showing the Distribution of the Sensory Nerves of the Skin of 

THE ^oot (Butler). 

167 



168 TREATISE OX NERVOUS DISEASES 

to pressure neuritis of a filament of a digital branch of the exter- 
nal plantar nerve lying between the heads of the metatarsal bones. 
Narrow shoes may favour its development, as may gout. 

The symptoms consist of sudden excruciating pain in or near 
dorsum of foot opposite the fourth toe. This pain shoots up the 
leg, and may be relieved by firm pressure, as of a lace shoe ; or by 
placing in the boot a " sole plate '' as manufactured by G-efvert. 

Prognosis in gouty cases is, however, bad. Excision of the head 
of the fourth metacarpal bone is the radical measure that we have 
seen effect a cure in several cases. 

Treatment of palsies of the various branches of the sciatic nerve 
outlined above consists in nerve suture for division; of getting 
rid of adjacent locah disease, as tumours, fracture, or callus; and 
in the treating of any diathetic tendencies. Other treatment useful 
is described under Sciatic Neuritis. 

RHIZOMELIQUE SPONDYLITIS 

This disease consists of an osteo-arthritis of the spine of un- 
known origin ; hence it can be set down as probably dependent 
upon trophic disturbance through the nervous system. Deformity 
may result, depending upon whether the interarticular vertebral 
fibro-cartilages are absorbed or not before the proliferation and 
ossification occurs about the respective joints. When the disks are 
absorbed quickly, kyphosis, scoliosis, and other deformities of the 
spine follow. The large joints near the body are next attacked, 
such as the hip. knees, and shoulders. The Roentgen rays show 
bony exudate and the absorption of cartilages as described. 

etiology is not definite. Heredity, cold, wet, and trauma or 
gonorrhoeal infection are all supposed to be factors in individual 
cases. But the above causes may be but exciting elements, the dis- 
turbed metabolism from lowered nutrition being the predisposing 
cause. 

Symptoms. — These are entirely dependent as to the nervous 
system upon trophic disturbance noted (also atrophy of muscles 
may occur as in two cases that are under the writer's care at the 
Philadelphia Hospital at the present time) or upon whether spinal 
nerves or spinal cord are encroached upon by pressure, etc. Pain 
and limitation of motion are usually prominent symptoms. The 
pain may be severe and be " referred," or occur at the site of the 
spine disease, usually then at anterior aspect in the back of abdo- 




Fig. 37.— Rhizomelique Spondylitis (Dorsal Spine). 
(Medico-Chirurgical Hospital) 

169 



170 TREATISE OX XEEVOUS DISEASES 

men. It is worse after sleeping^ probably due to sluggish circula- 
tion during sleep producing stagnation of circulation about a dis- 
eased area; also to metabolites irritating the sensory nerve roots. 
^^ Girdle pains " are one-sided usualty, because one side of the 
vertebral column is first attacked. There is impairment of mo-- 
tion in the legs; or, indeed, complete paraplegia may result. Close 
study may reveal areas of hypersesthesia, hypassthesia, or anaes- 
thesia depending on the lesion being at the time an irritative or 
destructive one. Coughing or movement of the head or trunk will 
bring on severe pain. According as the erosion of cartilage and 
osseous deposit predominates or muscular spasm is productive 
of the rigidity or deformity, will they be of more or less permanent 
nature. 

Prognosis. — Ultimately the patient may become entirely bed- 
ridden and helpless save for the use of the smaller joints. Occa- 
sionally the disease is stayed from advance by timely hygiene and 
treatment. 

Treatment consists of constitutional and hygienic measures. 
Sirup hypophos. comp., oi t. i. d., or cod-liver oil in cold weather 
are valuable nutritional drugs. Sod. salicylat., gr. x t. i. d., or 
potassium iodide, gr. x t. i. d., or syr. ferri, iodidi, a half drachm 
after meals, are respectively the best antirheumatics, alternatives, 
and haematics that can be employed. Look to the kidneys and the 
eliminative functions generally. A toxic process in the intestine 
may aggravate, hence the use of salol, gr. ii, in elix. lactopeptine, 
a drachm, thrice daily, may be desirable. The digestive tract 
must also be conserved in these patients and full simple diet given, 
including abundance of eggs and milk. The orthopaedic surgeon 
may aid by bloodless operation of extension or through applying 
apparatus,-or by use of a wheel crutch to get the patient about 
on his feet. I have had one case thus bettered, so that from being 
bedridden he could walk about. His general health was much 
improved. 



CHAPTER IX 
INFLAMMATION OF MENINGES 

DISEASES OF THE MEMBRANES OF THE BRAIN 

We shall consider here anaemia, hyperaemia, inflammation of 
the dura mater (pachymeningitis), and inflammation of the pia 
mater (leptomeningitis). 

Ancemia of the membranes of the brain cannot be well sepa- 
rated from anaemia of the encephalon itself, and must therefore 
be studied with anaemia of the brain. 

Hypercemia must likewise be considered with hyperaemia of the 
brain so far as that of the pia is considered. Dural congestion 
or hyperaemia may occur as the result of injuries, of sunstroke, of 
poisons such as uric acid, or of infectious diseases, such as mea- 
sles, scarlet fever, and syphilis; the symptoms beina: like those of 
pachymeningitis of the congestive stage, which will be described 
under that heading. The principal symptoms, are, however, ver- 
tiginous attacks and peculiar sensations of fulness in the head. 
The treatment is the same"as for the onset of meningitis. 

INFLAMMATION OF THE DURA OR PACHYMEN- 
INGITIS EXTERNA 

Since the so-called pachymeningitis interna is probably a haem- 
orrhagic disease (or haematoma of the dura mater), it will be de- 
scribed under the head of dural haemorrhage. It is extremely 
rare to have a true simple internal meningitis of the dura. (See p. 
175.) 

Pachymeningitis externa first involves the outer surface of the 
dura. There are less pressure symptoms than in haematoma. 

MENINGITIS 

This implies inflammation of the membranes of the cord and 
brain, being divided into pachymeningitis (dura) and leptomen- 
ingitis (pia), each in turn being divided into acute and chronic 

171 



172 TEEATISE ON NERVOUS DISEASES 

simple meningitis; and secondarily into acute and chronic infec- 
tious meningitis^ the latter including infectious cerebro-spinal 
meningitis/ tubercular, leptothrix infection, and the various strep- 
tococci infectious forms. Various other organisms produce in- 
flammation of the membranes, the principal ones, however, being 
included in the above list. Usually when we speak of meningitis 
we refer to meningitis of the dura, so that specifications should 
be made of these inflammations for the sake of exactness. 

ACUTE CEREBRAL PACHYMENINGITIS 

Inflammations of the Membranes of the Brain. — This may be 
'primary or secondary, the former being caused by the so-called 
" catching cold," or exposure to cold, or exposure to extreme heat. 
The causes of the latter form are infectious diseases, such as 
pneumonia, typhoid fever, infectious cerebro-spinal meningitis, 
injuries, carious bone as from mastoid disease, syphilis, erysip- 
elas, etc. 

Symptoms. — This disease is usually ushered in by a marked 
chill, followed by, as a rule, hyperpyrexia, the temperature run- 
ning up to 104° or 106° F. The patient may suddenly pass into 
convulsions of tonic and clonic nature, with retraction of the 
head, delirium, mania, and hyperemesis, frequently of the projec- 
tile type. -The convulsions may be localized or at least begin in 
one member, due to irritation of a particular centre over the motor 
cortex. Paralysis may follow. The pupils usually are irregularly 
dilated. There may be amblyopia, due to optic neuritis, which is 
soon set up in severe cases and accompanied by marked swelling 
of the disks. Various other palsies may occur, producing internal 
strabismus or externaj strabismus, frequently accompanied by 
diplopia. It is very rare that hemianopsia follows. Heaxing may 
be affected in the beginning, it being acute as is the case with 
the other special senses. Late in the disease deafness or dul- 
ness of hearing may occur. Localized facial palsies may also 
follow spasm of these muscles, due to the involvement of the 
nuclei of the facial nerves. If the basilar membranes are involved 
bulbar symptoms may supervene; or a deafness, or blindness in 
the most serious cases. The duration of acute pachymeningitis will 
depend upon the degree of infection or the resisting power of the 
patient. Death may follow early severe convulsions. The acute 



IXFLAMMATIOX OF MEXIXGES ITS 

symptoms maj" last a week or ten days, when termination by crisis 
may occnr.^ Or, as is the rule, a gradual defervescence of the 
fever and recovery with more or less seqnelse, depending npon the 
severity of the disease. 

Prognosis. — In children it is worse than in adults, owing to the 
lack of resistance throngh immature development of the nervons 
system in them. Occasionally a ease will recover with apparently 
absolute integrity of the nervons system and no sequelae whatever, 
but in the vast majority of cases some defect is left l^ehind, either 
blindness, due to progressive atrophy of the optic nerves, or deaf- 
ness from involvement of the acoustic nerves, etc. These two spe- 
cial senses are the most frequently involved, although the others, 
but very rarely, may also be affected. Sequelse, as hemiplegia, 
paraplegia, or monoplegia of spastic type, depending upon the de- 
gree of involvement of the motor cortex, are frequent. 

Treatment. — This will depend entirely upon the nature of the 
cause. If primary disease or any septic foci exist in the body, these 
should be dealt with at once. (The treatment of infectious cere- 
brospinal meningitis will be considered in its proper place.) 

The patient should be, as a rule, placed in a dark room, in quiet 
surroundings, and well protected from atmospheric exposure. 
Such measures are necessitated by the extreme hyperexeitability in 
the beginning of the disease. Hyperpyrexia should be treated 
by antipyretics guardedly administered, by the sponge-bath or ice- 
pack, and in some cases of plethoric individuals venesection should 
be tried. The application of leeches to the temple or wet cups to 
the nape of the neck are valuable methods of depleting the con- 
gested meninges; to-day not enough used. For the control of con- 
vulsions, the antipyretic measures detailed may he sufficient in the 
milder cases, but in the more serious ones the use of large doses 
of bromides and chloral may be necessary. If these cannot be 
retained by the stomach they should l^e given per rectum, and in 
twice the dosage as given by the mouth. If heart failure occurs 
later in the course of the disease, cardiac stimulants may be 
necessary, such as digitalis, or in acute syncope hypodermics of 
ether or strychnine may be necessary, continued until the crisis 
is past. In case of injur}' or abscess, surgical help must l^e sought. 

^ Kernig's sign mar be present in meningitii? — riz.. the inability to extend 
the legs -while sitting, but ability to do so when rec-nmbent. It is nrA pathog- 
nomonic of the disease. 



174 TKEATISE OX NEKA^OUS DISEASES 

Potassiiim or sodium iodide are valuable remedies for the absorp- 
tion of the exudate. If betterment of ocular troubles does not 
occur with this, the destruction of the cranial nerves passing out 
at the base of the brain may be inferred and a basilar type 
confirmed. The treatment of sequels, as optic atrophy, etc., will 
be the province of specialists in this department of medicine, to 
whom the case should be early referred. Epilepsy may be a sequel, 
and should be treated symptomatically if the original source of 
irritation cannot be removed. 

Causes of Chronic Meningitis. — This is generally the result of 
the acute form. Some cases are so insidious that they are desig- 
nated subacute or chronic from the first discovery of symptoms. 
Sunstroke is quite frequently a cause of this type, as may be lues 
or trauma. 

Symptoms. — Persistent headache of a dull character, worse 
when the patient is exposed to heat or when he stoops forward 
or lies down. He also complains of pain in the neck, frequently 
radiating towards the shoulders, and may suffer from general 
paresis of the extremities, usually of a spastic nature. Or he may 
be the subject of deafness, vertigo, or optic atrophy. Such pa- 
tients, too, may be subjects of secondary epilepsy. 

Diagnosis. — This is to be made from chronic cerebritis, tumour 
of the brain, hydrocephalus. In cerebritis there is usually more 
mental failure or even dementia with less spasticity of any existent 
palsy. In tumour of the brain the special predominance of optic 
neuritis (95 per cent), together with localizing symptoms, will 
differentiate, while in hydrocephalus, the enlargement of the head 
of the peculiar metallic sound on percussion, or the exophthalmos, 
are points for differential diagnosis. 

Prognosis. — This is usually bad as to permanent recovery, the 
patient being liable to exacerbations at any time, due to catching 
cold or exposure to heat. In adults the chronic form of menin- 
gitis may exist for many years. In cMldren, since interference 
of development of the brain follows, life is materially curtailed 
even in the milder cases, such patients usually succumbing early to 
intercurrent disease. Blindness and deafness occur in the chronic 
form as the result of the acute type, and as a rule such cases are 
practically incurable. Imbecility is not unusual. 

Treatment. — This will simply consist of additional measures 
to those already referred to — namely, the treatment of the convul- 



IXFLAM^IATIOX OF MEXIXGES 175 

sions or of contractures and of palsies, which hitter may require the 
services of the orthopaedic surgeon. Massage and Swedish move- 
ments should be given a fair trial in these cases. If a large exu- 
date, especiallv of the haemorrhagic type, or a localized blood tumour 
of the dura exists, the surgeon may by prompt operation save the 
patient's life, as I have known in one case. Extensive counter- 
irritation over the scalp is of value. 

CEREBRAL PACHYMENINGITIS INTERNA H>^MOR- 
RHAGICA OR Hy^MATOMA DURA 

This is a type of local inflammation involving the internal 
layer of the dura. It is more frequent in male adults and in those 
subject to chronic alcoholism or prolonged intoxication. 

8ymytoms are insidious, the patient complaining of pain in the 
head, following an alcoholic debauch. There are manifest symp- 
toms of dementia, such as loss of memory, incoherent speech, with 
periods of excitement. Frequently the patient will pass into an 
uraemic state, which is due no doubt to kidney insufficiency at the 
time, even though the kidneys may not be permanently disabled. 
The case may recover from the uraemic attack . rather suddenly. 
Usually within a few days or a week recurrence of symptoms oc- 
curs, such as added weakness of the extremities, more pronounced 
upon one side of the body. Fifty per cent of the hgemorrhages are 
on one side of the dura. The mental obtundity deepens, the pa- 
tient passes into delirium. There is also noticed general tremu- 
lousness. It will be found, too, that the paralysis is much more 
spastic than the rapidity of onset and the extent of motor weak- 
ness would warrant. This is a point of value in making the diag- 
nosis of this serious malady. A distinct point in the symptomatol- 
ogy is, therefore, exacerbations and remissions without profound 
coma at any time until late in the disease. 

Diagnosis. — This disease is so difficult to diagnose that it seems 
useless to set down differential points. Ingravescent haemorrhage 
into the cerebrum may be mistaken for it, as well as uraemia, indi- 
cated above. From the former it may be distinguished by the 
more exact symptomatology of true apoplexy in the latter. From 
uraemia, the urinary examination would be of great value, since 
the lesser bulk of albumin, if any, would be found in a meningitis. 

Prognosis. — This is absolutely bad. The patient is usually car- 



176 



TREATISE OX XERVOUS DISEASES 



ried off within ten days after the onset of symptoms. Death gen- 
erally occurs not alone perhaps from the haemorrhage, which is 
usually massive and spread over the entire cortex of one side, but 
very likely it is completed by the general alcoholic toxaemia existent 
in these patients. " 

Treatment. — This consists, therefore, in the same form as the 
acute meningitis given above. Surgical treatment is not as yet 




Fig. 38.— H.emorkhagic Pachymeningitis Interna (Alcoholic). S]^eciinen 
from a case in the Philadelphia Hospital. (Dura is reversed in the photograph.) 



fully developed, and has not been resorted to in many cases, but 
would seem to be the only possible chance of saving the patient's 
life. If it were not for the extreme asthenia, a diagnosis could 
be made and the surgeon's skill in trephining and removing the 
clot might save some cases. Venesection and transfusion of nor- 
mal salt solution is a treatment that should be resorted to in 



INFLAMMATIOi^ OF MENINGES 177 

cases of marked toxaemia. Supportive measures should, of course, 
be insisted upon in all these cases. 

CEREBRAL LEPTOMENINGITIS 

This is usually an acute infection. It is, as a rule, secondary 
to some septic foci, as abscess of the lung, liver, etc. 

Symptoms. — These are fulminating in character, accompanied 
by high temperature, great mental anxiety, and a hectic type of 
temperature curve, which remains, at about 104° or 106° F. Con- 
vulsions are not so common, nor spactic rigidity of muscles so 
frequent as in the acute form of pachymeningitis, nor is intense 
head pain of so great importance as in the former disease. Local- 
ized palsies of sudden development are rather frequent, depending 
upon exudation over a motor centre. Duration of the disease is 
from a few days to ten days, the patient usually succumbing with 
the hyperpyrexia or from the general infection. Termination by 
crisis may occur, or a chronic septic inflammation of the brain 
may result. 

Prognosis. — This is bad in the majority of cases. Death of 
the patient usually takes place within seventy-two hours. In many 
cases a remote ahscess in the brain may be the result of the above 
disease. 

Treatment. — This would not be different from that for pachy- 
meningitis excepting that it is more incumbent to seek for septic 
foci both in the brain and in other organs, to which it is so fre- 
quently secondary. 

HYDROCEPHALUS 

■ This is a condition, congenital or acquired, in which there 
is an accumulation of the fluid within the ventricles of the brain. 
There are two types of hydrocephalus, external and internal. It is 
again divided into acute and chronic, although the chronic form is 
the more common variety. The internal type implies an excess- 
ive collection of fluid within the ventricles, whereas the external 
type refers to cases in which the fluid is mainly in the subdural 
space. Usually the two are coexistent, but internal hydrocephalus 
always predominates. 

Symptoms of acute Jiydroceplialus may follow acute inflam- 
mation of the ependyma. It is more usual in babyhood and in 



178 TEEATISE ON NERVOUS DISEASES 

children suffering with marasmus, in which subjects there seems to 
be a special tendency to local inflammation of this serous lining of 
the brain. Symptoms are those of subacute meningitiS;, excepting 
that convulsions are not so frequent and the temperature is never 
so high as in the former disease. The child is usually in a condi- 
tion of muscular rigidity, however, the attack itself generally being 
induced by autointoxication. In addition to the muscular rigidity 
with. tetanic spasms, at times there is evident an enlargement of the 
head, bulging of the fontanelles, and depression of the eyeballs 
within the socket, together with exophthalmos. The vault of the 
cranium projects out in proportion to the rest of the skull, so that 
there seems to be enormous enlargement above the ears. In some 
cases the sutures are seen to be separated and the Wormian bones 
palpable. The " hydrocephalic cry," consisting of a long, deep re- 
spiratory sound, is a very usual symptom. Percussion over the 
skull will frequently produce a pseudo-tympanitic note, and on aus- 
cultation over the skull a distinct bruit can be detected synchro- 
nous with the pulse-beat. The patient may finally pass into a con- 
dition of tetany and die from exhaustion. 

Pathology consists of subacute ependymitis with excess of 
serum within the ventricles, which may, as indicated, also extend 
to the arachnoid. 

Prognosis. — This is* bad, as a rule. In the acutest forms life 
becomes extinct within a few months. Occasionally the symptoms 
abate, and the patient is left with the chronic enlargement of the 
head which, if not too extensive, will not produce paralysis of the 
extremities nor any considerable degree of mental impairment, 
the rule, however, being that cases will result in imbecility with 
the general symptoms of spastic paralysis of childhood. It should 
be remembered that this is frequently a congenital condition, which 
is lit up soon after birth. It is astounding to what degree the 
convolutions may be pressed upon, and life and fair mentality be 
preserved in a small number of cases. 

Treatment is hygienic, medicinal, and operative. Prophylac- 
tic measures should be part of the treatment — nourishment of the 
child predisposed or born with the condition is most essential. 
Inunctions of cod-liver oil, with the idea of gaining weight and 
greater resistance to diseases, is of value. Spasms should be con- 
trolled by chloral and bromides. Sodium iodide is especially of 
service in infants, being less liable to disturb the stomach. It 



INFLAMMATION OF :\[EXIXGES 170 

should be given in two-drop or three-drop doses of a saturated solu- 
tion, gradually increased to the ph3'siological limit. Some advise 
compression of the skull by proper bandaging with the idea that 
this may tend favourably against the formation of exudation. 
Should symptoms of compression develop, however, the bandage 
should be removed immediately. Surgical aid through craniec- 
tomy, or tapping the ventricles, under antiseptic precautions, may 
be of value as a dernier ressorf. 

Chronic Hydrocephalus. — This is usually the result of the acute 
form of hydrocephalus, and from the evidence found at birth in 
same cases, it is apparently chronic from the very first — i. e., it 
has existed some time in the prenatal life of the child. The signs 
here may first be noted during labour, an enlarged head being the 
cause of dystocia. More frequently, however, the hydrocephalus 
becomes apparent some time after birth. 

Causes of this condition are not definitely known. The pathol- 
ogy offers no direct clue to the nature of the trouble. The lateral 
ventricles are greatly distended, but the ependyma is usually clear, 
occasionally granular and thickened. The chorioid plexuses are 
extremely vascular. The third ventricle is dilated, as is also the 
aqueduct of vSylvius and the fourth ventricle. The quantity of 
fluid may be several litres. It contain^ salts, albumin, etc. 

The cerebral cortex is greatly stretched, and over the middle 
region it may measure but a couple of millimetres. The basal gan- 
glia are flattened. The bones are extremely thin, and the Worm- 
ian bones themselves may gradually extend, due to the effect on 
the part of nature to fill in the gap of the widely separated edges 
of the bones. 

Symptoms are similar to those of the acute type, although not 
so severe. Convulsions may occur, reflexes are increased, the child 
may learn to walk late, but ultimately usually becomes feeble and 
very spastic. The mental condition is widely variable, from that 
of the ordinary imbecile to that of average intellect. 

Dmgnosis. — The rhachitic head should be told from that of 
acute hydrocephalus, and is known, too, by the other evidences of 
the enlargement of the epiphyses of the long bones. The head in 
rickets is usually square, and not round or globular. The sepa- 
ration of the bones of the skull is not usual, nor is there the 
tympanitic note produced on percussion over the skull nor the 

bruit heard on auscultation, as in hvdmcephalus. 
12 



180 



TREATISE OX NERVOUS DISEASES 



The acquired form of chronic hydrocephalus is simply the re- 
suit of acute "hydrocephalus, but is said by some writers to be 
primary, essential, or idiopathic ; that is to say, it comes on spon- 




; , -rT .TKtt:^ 



Fig. 39. — Brain. Case of Hydrocephalus in a Child of Five Yeaes. Size 
indicated in inches (reduced). — (Howard Hospital.) 



taneously in the adult without observable lesion. Osier quotes the 
statement of Mr. Whiteway that Dean Swift was a subject of this 
variety, but doubts the possibility, and assumed that his ease was 



IXFLAMMATIOX OF MENINGES 



181 



probably one of a spurious form of hydrocephalus, ex vacuo ; that 
is, within the arachnoid alone. The symptoms of the acquired 
form would vary with the time in life of its development. If 
developing early, the symptoms already rehearsed will be present; 
if late in life, the patient will suffer from headaches, the gait 
hecoming gradually irregular and ataxic; with a spasticity, how- 




FiG. 40.— Spastic Diplegia from Chkonic Hydrocephalus (Adult Male). 
(Philadelphia Hospital.) 



ever, which distinguishes it from other forms of gait. In some 
cases there will be prolonged attacks of coma with slow pulse, due 
to irritation of the vagi nuclei by the pressure. One case on record 
is reported to have been unconscious for three months. Optic 
neuritis soon supervenes, and in the worst cases rapidly progresses 
after once begun. Chronic purulent ependymitis may precede 
death in some cases. 



182 TREATISE ON NERVOUS DISEASES 

Meningitis serosa is a type distinguished by Quincke, and con- 
sists of serous meningitis as distinguished from ordinary lepto- 
meningitis and from hydrocephalus. Quincke describes the 
affection as coming on suddenly in children with intense pain in 
head, signs of intracranial pressure, slow pulse, and choked disks. 
Retraction of the head exists, without fever, however. Some cases 
are much more insidious and are frequently mistaken for brain 
tumour. 

Treatment consists in the relief of pain and in making an effort 
to cause absorption of the collected fluid. This will be best done 
by giving depletive remedies, such as gamboge in sthenic individ- 
uals, or podoph3dlin or even calomel in repeated dosage. For the 
more usual asthenic cases such harsh treatment cannot be carried 
out, and we must depend upon free diuresis, producing in- 
creased action of the skin through such drugs as pilocarpine. 
Potassium iodide is a valuable remedy as a sorbefacient. Bichlo- 
ride of mercur}^, added to the above iodide, may favour resorp- 
tion of the exudate within the brain. As a prophylactic measure 
the patient should be carefully guarded against inclement weather 
and given nutritious diet; and mental strain should be avoided. 
Skilled massage may be of value in these cases. 



CHAPTEK X 

DIFFUSE AND LOCAL DISEASE OF THE BRAIN 

Cerebral Localization (Epitomized). — It must be remembered 
that cerebral localization is not an exact science, because symptoms 
may also be produced by compression, causing irritation, paresis, 
or paralysis of adjacent centres ; also, that circulatory disturbances 
occurring in the course of disease of the membranes of, or of the 
encephalon itself, may cause wide-spread functional disturbance 
that disobey all scientific rules. ^ Still, in the majority of instances, 
close day-to-day study of the case will be rewarded by brilliant 
diagnoses, and help, therefore, for the patient. The accompany- 
ing illustrations (Figs. 4-1 and 42) give the respective locations of 
the definitely know centres in the cerebrum. Beginning from the 
posterior aspect, we will enumerate the function of each centre 
and lobe (for fuller description, see Chapter I, on Anatomy, etc.). 

Occipital Lobe. — Here lie the centres of vision, destruction of 
which causes cortical blindness (in the absence of lesion of the eye 
or optic nerve). Hemianopsia may also result as indicated under 
diseases of the optic nerves. Sensory centres are also present in 
the occipital lobe. (Cortical centres concerned in speech are de- 
scribed under Aphasia.) 

Temporal Lobe. — Here lies the centre of audition — i-. e., for 
word hearing — in the posterior part of the first and second convo- 
lutions — and the centre for naming in the third convolution. 

The central convolutions of the parietal and frontal lobes of 
the cerebrum are principally centres for voluntary motor func- 
tion. The upper portion of the first and second frontal govern 
movements of eyes and head. These centres OTerlap one another. 

These convolutions probably also receive sensory impressions 
from the skin, muscle, and very likely from the viscera, and thus 

^ See Some Points on Intracranial Neoplasms considered from the Neu- 
ronic Standpoint, by the author. Read before the Section on Medicine, New 
York Academy of Medicine; Philadelphia Medical Journal, November 16, 
1901. 

12* 183 



184 



TREATISE OX XERYOUS DISEASES 



are the cortical sensory centres for muscle and tactile sense, the 
superior parietal lobule being probably the location where sensa- 
tions from the muscles are received. 

Irritative lesions in the motor cortex cause local spasms ( Jack- 
sonian epilepsy), or general convulsions. There may also be par- 
aesthesia of the. parts convulsed, due to vaso-motor paresis. 



Superior frontal sulcus. 



Fissure of Rolando. 



Interparietal sulcus. 




Ascending ramus 
of the fissure 
of Sylvius. 



Fissure of Posterior ramus of the Superior temporal 
Sylvius. fissure of Sylvius. sulcus. 

Fig. 41. — Schematic Representation of the Cerebral Cortex and 
ITS Centres. (After Tillmanns.) 



1. First. 

2. Second. 

3. Third. 

4. Anterior. 

5. Posterior. 

6. Upper. 

7. Middle. 

8. Lower. 



9. Upper. 
10. Lower. 



Frontal couvolulion. 



Central convolution. 



> Temporal convolution. 



Parietal convolution. 



11. Gyrus angularis. 

12. Upper. I 

13. Middle. ^ Occipital convolution. 

14. Lower. ) 



© In 4 and 5 on both sides of the fissure of 
Rolando, motor area for the upper 
extremity. 

Moror area partly for the upper and partly 
for the lower extremity (.great toe). 

Motor area for the lower extremity. 
Cortical area for the hypoglossal nerve. 
Cortical area for the facial nerve. 

^ (3) Motor aphasia. 

X (6) Sensory (auditory) aphasia with word- 
deafness. 

'r (11 ) Aphasia with word-blindness. 

• (12i Region of the visual area (see also 
Fig. 10). 



Destructive lesions involving these same central motor convo- 
lutions cause paralysis of the muscles of the opposite side of body, 



DIFFUSE AND LOCAL DISEASE OF THE BRAIN 185 

which soon become spastic. The paralysis is not always complete, 
since only a few centres may be involved. Muscles acting together 
(as of respiration) or those which express emotion (as the facial), 




F.po. 



S.h. 

Pig. 42. — View of the Right Cerebral Hemisphere from the Median Side. 

B, corpus callosum divided longitudinally ; (?./., gyrus f ornicatus ; H, gyrus hippocampi; 
S.h., sulcus hippocampi ; G. u., gyrus uncinatus ; S. c. m., sulcus calloso-marginaUs ; F. 1, 
first frontal convolution; S. c, termination of the fissure of Kolando; in front the 
anterior central convolution with the motor area partly for the upper and partly for 
the lower extremity, and behind the posterior central convolution with the motor area 
for the lower extremity ; P, praecuneus ; C, cuneus ; F. po., parieto-occipital sulcus ; p, 
polus ; F. c, calcarine fissure ; in the posterior part of this the visual area is shown by a 
red dotted line. (After Tillmanns.) 



being represented on both sides of the cerebrnm, are not com- 
pletely palsied. Asteriognosis, or disturbance of sensation, may 
be found if the lesion extends to the posterior part of the parietal 
lobe. 

The cells of the ascending frontal or precentral convolution, 
the ascending parietal or post-central convolution, the superior 
parietal lolule, the upper portions of the first and second frontal 
convolutions, part of the cuneus, the paracentral lobule, all con- 
trol or originate voluntary motor impulses. These same centres 
also receive sensory impressions; hence this region of the brain is 
designated the sensorio-motor region. The trunk muscles and 



186 TEEATISE ON NERVOUS DISEASES 

Ipg muscles are largely represented in the upper portions of the 
precentral and post-central convolutions. The muscles of the 
arm have their centres in the middle third of the precentral and 
post-central convolutions; the face, tongue, larynx, and pharynx 
being represented in the lower part of these same gyri. 

The Prefrontal Eegion. — This consists of the part of the fron- 
tal lobes in the anterior part of the third and ascending frontal 
convolutions. The centres that have to do with higher mental 
faculties (higher psychical centres) lie here — viz., those of judg- 
ment, reason, memory, attention, and comparison. It is the great 
association centre (Bianchi). It also is supposed to be a centre 
for the trunk muscles, according to Munk. 

Centrum Ovale. — Lesions here may involve association, sensory, 
or moior fibres. A subcortical lesion may simulate a cortical palsy, 
but there is not likely to be spasm at any time except after inva- 
sion of the cortex. Hence, spasm always follows paralysis, just 
the opposite to that in cortical lesions. When the lesion is near 
the internal capsule the palsy resembles that due to lesion of it. 
There may be hemianopsia, hemiansesthesia, and if lesion is on the 
left side, aphasia in disease of the centrum ovale. 

Corpus Callosum. — Symptoms are of partial or complete palsy, 
a hemiplegia gradually extending to the opposite side, with later 
development of dysphagia, dysarthria, and an insidious dementia. 
A double cortical lesion may, however, closely simulate symptoms 
of disease of the corpus callosum, but the greater asymmetry in 
the degree of muscle weakness would be in favour of cortical 
disease. 

Corpus Striatum. — The function of this ganglia is not defi- 
nitely known. It is very likely that, as excision experiments on 
dogs lead to suspicion of (and in a case under the care of Dr. 
John M. Swan and the writer, one of Friedreich's disease with tem- 
perature, which seemed to point to its degeneration as a cause of 
the pyrexia) the existence of a centre for heat, regulation is in the 
striatum. 

Optic Thalamus.— This important ganglia is joined with the 
cortex of the frontal, temporal, parietal, and occipital lobes. It is 
the site of the ultimate ending of the optic tracts as well as of 
some sensory fibre neurones, which latter extend through their 
axons to the cortex. Very likely the main centre of regulation 
of body heat is in the thalamus. With the external geniculate 



DIFFUSE AND LOCAL DISEASE OF THE BRAIN 187 



hodij and corpora quadrigemina the posterior part of the thalamus 
forms the 'primary optic centre. 

The corpora quadrigemina, with the other two bodies just enu- 
merated, form the primary visual centres. The remaining part of 
these centres control the reflex movements of the iris and ciliary 
muscles. The posterior bodies also, together with the internal 
geniculate bodies, are joined with the cerebellum and auditory 
centres, hence control in part sen- 
sations of space and audition. 

Internal Capsule. — The motor 
and sensory projection fibres (or 
peduncular fibres) pass within 
very narrow compass through the 
internal capsule. In the region of 
the " knee " are fibres which pass 
from the cortex to the motor 
nerves of the eye, to facial and 
hypoglossal nerves, also those 
fibres which pass to the nuclei of 
the nerves that govern the other 
muscles that have function in 
speech, which are supplied by the 
vagus. The pyramidal tract fibres 
lie next posteriorly, those of the 
leg being also posterior to the 
arm. Posterior to all of these are 
the fibres that transmit common 
sensation and special sense im- 
pulses (hearing, vision, taste, 
smell). 

As the pyramidal tract fibres 
are in a very compact mass in the capsule, a lesion here produces 
hemiplegia on the opposite side of the body, monoplegia being 
never produced by snch a located lesion. If the lesion is in the 
posterior part of the capsule hemiansesthesia will result, associated 
or not with homonymous hemianopsia, and with muscular paresis. 

Crus Cerebri. — A lesion of the crus will cause spastic palsy 
or paralysis upon the opposite side of the body, with palsy of 
muscles supplied by the motor oculi, since this nerve makes its 
superficial exit from the crus. The optic tract, as it crosses the 




Fig. 43.— Diagram of Motor and 
Sensory Representation in the 
Internal Capsule. 

NL., Lenticular nucleus. NC, Caudate 
nucleus. THO., Optic thalamus. The 
motor paths are red and black, the sen- 
sory are blue. (From Osier's Practice of 
Medicine.) 



188 TREATISE OX NERVOUS DISEASES 

cms, may also be affected, producing homonymous hemianopsia. 
The tegmentum may, however, be involved without disease of the 
fibres of the crus, in which instance disturbance of common and 
muscular sensibility may occur associated with ataxia of the oppo- 
site side of the body. 

The Pons Varolii or Bulb. — The gray matter here consists of 
cells which form nuclei of the peripheral neurones of the motor 
division of the fifth; also the sixth and seventh nerves. The pons 
is the centre for the ascending or sensory nucleus of the fifth nerve ; 
also for the sensory and motor tracts on their way to and from the 
cortex. There are also neurones in the pons which connect with 
the cerebral and cerebellar cortices. 

Cerebellum. — Here the gray ganglionic masses are in the cen- 
tre, but the gray matter proper is upon the cortex. The vermis 
or middle lobe is alone known positively as to function, and is 
joined with sensory and motor paths of both brain and cord, the 
auditory nerve, some of the nuclei in the pons, and with the infe- 
rior olivary bodies of the medulla. The functions of the cere- 
bellum are not definitely ascertained in detail. It is known to 
take part in maintaining the equilibrium of the body, in muscular 
movements, and in maintaining our relations to surrounding ob- 
jects. Hughlings-Jackson claims that disease of the cerebellum 
causes palsy of the trunkal muscles also, and that the cerebellum 
maintains muscle tone. 

Medulla Oblongata. — The lower motor neurones or nuclei of 
the eighth to twelfth cranial nerves lie here, except the spinal root's 
centre of the eleventh, which is in the cord. The oblongata is 
of course only the expanded portion of the cord, and the cells 
lying here have the same sort of function as do those in the gray 
matter oi the cord. 

In the medulla are also found refiex and automatic centres 
controlling the respiratory and circulatory functions, secretion, 
and the visual movements. The olivary bodies (superior and in- 
ferior) are small masses of gray matter in the medulla, and are 
joined with the basal ganglia, cerebellum, and cord, having to do 
in part with co-ordination and equilibrium. 

A lesion high up in the oblongata may damage the pyramidal 
tract above its decussation and the hypoglossal nerve upon the 
same side as the lesion, producing an alternate paralysis. 

Affection of the nuclei gives rise to the so-called bulbar symp- 



DIFFUSE AXD LOCAL DISEASE OF THE BRAIX 189 

toms — those of glosso-lalno-pharyngcal paralysis. Death may fol- 
low suddenly from involvement of the respiratory or cardiac cen- 
tres. Polyuria or glycosuria may also result from chronic lesions 
of the medulla. 

The functions of the occipital lobe have been mentioned 
under diseases of the optic tract. 

Cortical centres concerned in speech are to be described next 
under Aphasia. 

APHASIA 

By this we mean disturbance of the power of communication 
by the ordinary signs of language. The word aphasia, which 
signifies loss of speech, is the general designation applied to all 
forms of defects of the elements of speech due to disease of the 
cerebral hemispheres. This is usually a lesion involving the cor- 
tical centres of the speech mechanism.. Aphasia is to be distin- 
guished from disturbance of speech that follows mechanical trou- 
ble with articulation due to lesion of peripheral organs or nerves, 
and also from speech defects due to the lesion of the cranial nuclei 
or of the association and co-ordination tracts of speech in the ob- 
longata, pons, and cerebellum. Aphasia is, therefore, limited to a 
partial or complete loss of the power of comprehension or expres- 
sion of language. It is divided into two classes — motor and sen- 
sory aphasia. The former may be designated emissive, and the lat- 
ter a receptive type. Of the motor form we have subdivisions con- 
sidered as elementary — namely, (1) aphasia, or complete motor 
aphasia, (2) agraphia, or inability to write. 

Of the sensory form we have (1) word-deafness, or auditory 
aphasia, and (2) word-blindness, or visual aphasia. Mills desig- 
nates another form of elementary aphasia — namely, verbal, or that 
variety which is due to the lesions of the naming centre. Apraxia 
is the form where the patient is not able to understand the uses 
of objects. 

Motor Aphasia. — Aphemia, as Brocker, Ross, and others have 
designated motor aphasia, is divided by some into two or three 
forms, the first being strictly limited to that produced by lesion of 
the foot of the left third frontal convolution, the so-called Broca 
convolution. Broadbent names another variety, in which the lesion 
is at the foot of the second central convolution back of the Broca 
centre. Total destruction of Broca's convolution in ria-ht-handed 



190 



TREATISE OX NERVOUS DISEASES 



people makes spoken speech impossible for a lime at least. Later, 
the hitherto untrained centres in the right third frontal convolu- 
tion develop. The patient may thus acquire or regain partiall}^ the 
faculty of speech. Usually, however, recovery in part is due to the 
fact that the centre was not entirely destro3^ed. The reason for the 
speech centre being on the left side is, theoretically, assumed to 
be that this side is much more highly developed than the other, 
in obedience to the principle of the economizing energy, most peo- 
ple being also right-handed. Articidative ataxia is nothing more 
than the old ataxic aphasia, so-called, or the asynergia verhalis of 
Lordat — i. e., the existence of incomplete motor aphasia, which is 




Fig. 44.— Zones and Centres. External Aspect. Cerebrum. (After Mills.) 



generally the sequel of the complete form. Most cases of motor 
aphasia also suffer from agraphia. This loss or defect may be due 
to lesions of the centre for word-seeing, which centre is placed at 
the caudal extremity at the second or medio-frontal convolution, 
and in close relationship with the upper or mesial boundary of , the 
true speech centre. True agraphia is an almost invariable result 
of destruction of Broca's centre, however. It is probable, as Wiley 
concludes, that motor agraphia, as far as writing with the right 
hand is concerned, may result from a lesion in the graphic centre 
in the posterior portion of the second frontal convolution. 

Pantomime study is only second in importance to that of 
spoken speech in the consideration of aphasia. It is in general 
a part of speech, and so closely associated that disturbance of 



DIFFUSE AND LOCAL DISEASE OF THE BRAIN 191 

speech is always accompanied by disturbance more or less of pan- 
tomime. 

Amemia is loss or impairment of power of expression by signs, 
when due to cerebral disease. 

Paromemia is confusion of the signs in efforts at expression 
through them. 

Sensory or Receptive Aphasia. — This is considered usually as 
having three special forms: (1) auditory aphasia, or word-deaf- 
ness; (2) visual aphasia, or word-blindness; (3) and apraxia, also 
called mind-blindness, soul-blindness, and object-blindness. Physi- 
ological investigations, including those of Ferrier, prove (1) word- 
deafness is due to lesion in the posterior third or first and second 
temporal convolutions, as verified by Mills, who contends " that it 
is not complete unless the corresponding region on the right hemi- 
sphere is also impaired or destroyed." Other symptoms present in 
this form are inability to read aloud correctly. The patient is un- 
able to verify what he reads by hearing. In the complete form he 
cannot echo spoken words. Paraphasia and paragraphia may also 
be present in these cases, as may also verbal amnesia, and as may 
articulative amnesia. But it is probable that in some of these 
cases the amnesic phenomena are due to the involvement of the 
centre, or of tracts leading from the centre of word-hearing to the 
conceptional or motor centres. Music-deafness may be associated 
with word-deafness. But from the fact that it is sometimes pres- 
ent when auditory aphasia is absent, it is assumed that in some 
people the faculty for music belongs in both hemispheres of the 
brain to a greater degree than does the faculty of hearing. Be- 
tween the auditory centres at the base of the brain and the cortical 
auditory centres in the left temporal lobe are also entering tracts 
for hearing. A lesion of these tracts, which probably go from 
both sides of the brain, will give rise to a form of word-deafness. 
Lichtheim has placed the entering auditory tracts chiefly in the 
left temporal lobe. A lesion of this tract will cause outer word- 
deafness. A case of lesion restricted to this entering tract alone 
has been reported by Lichtheim. We must have entire comprehen- 
sion of cortical anatomy aphasia and complete understanding of 
the auditory path before this matter becomes clear. 

(2) Visual localization, like auditory localization, has also cer- 
tain tracts to be considered from an anatomical and ph3^siological 

point of view before we can understand amblyopia, hemianopsia, 
13 



192 TEEATISE ON NERVOUS DISEASES 

etc. Henschen believes that the centre for the macular field lies 
in the calcarine cortex. There is also doubtless stored near the 
visual centre images of words, letters, and probably of objects. 



Pig. 45.— Zones and Centres. Mesal, Aspect. Cerebrum. (After Mills.) 

This is likely in the angulo-occipital region or on the lateral 
surface of the hemisphere, as located by Ferrier. Partial destruc- 
tion will produce word- or letter-blindness. 

Alexia, or the inability to read, will, of course, be produced 
by such a lesion as will cause agraphia so far as this is dependent 
upon sight. Patients who have been rendered alexic or word-hlind 
(lesion of centre for word-seeing) can sometimes write their names 
or simple words; apparently doing so through touch or by recog- 
nition of psycho-motor im.ages. Between the primary optic cen- 
tres at the base of the brain and the cortical centres recited are 
certain entering tracts for vision (optic radiations of Orateolet). 
It must be remembered that the primary cortical visual centres are 
connected with half of the retina on each side — the same half on 
which the centre lies — the fibres passing to the angular region in 
each hemisphere. This is the centre of e3^e functions. A lesion 
which severs the tracts coming from both occipital lobes to higher 
centres will cause word-blindness, but not agraphia. Commonly 
such a lesion will also produce hemianopsia, since the radiations 
of Grateolet are usually involved. 

(3) Not infrequently associated with word-blindness is another 
disorder, which has been, variously called mind-hlindness, soul- 
blindness, and object-blindness. In examining for this, the physi- 



DIFFUSED AND LOCAL DISEASE OF THE BRAIN 193 

cian tries to determine if the patient shows signs of recognition of 
various objects. He may not comprehend the use of the simplest 
things and he may not recognise intimate friends, excepting by 
touch or by hearing their voices. (Occasionally there is added to 
this form a psychic deafiiess in which the patient cannot recognise 
a friend by the sound of the voice.) The centre for mind-blind- 
ness may or may not be separate from the centre for visual images 
of words (visual aphasia). Both hemispheres of the cerebrum 
doubtless take part in the storing of images in equal degrees. The 
mental percepts of objects and of names are the results of defi- 
nite processes of cerebration (Mills). Ideation is particularly dis- 
turbed through lesion of the radiating fibres, whereas the determi- 
nation of names is disturbed through lesion of the centres for per- 
cepts only. 

Mills, with Broadbent, holds the view that a naming centre 
exists in the cortex of the brain. Destruction of this centre will 
produce verbal amnesia. A form of verbal amnesia, called articu- 
lative amnesia, would be due to partial destruction of this centre. 

Conducting aphasias are those forms of speech disturbance 




Fig. 46.— Flechsiq's Association Areas— Lateral Aspect. 



which are due to defects or destruction of the tracts associating 
various regions concerned in the mechanism of speech. Some of 
these are paraphasia; paragraphia, the misuse of words in writing; 
paramemia, the misuse of signs; paralexia, misuse in reading of 



194 TREATISE OX NERVOUS DISEASES 

syllables or words; and dyslexia, which is difficulty or fatigue 
shown in reading. 

Examination for Aphasia. — First: determine as'sociated phe- 
nomena of aphasia^ as gesture language, already detailed. Test 
for these carefully. Second: extra-graphic symbols should be 
sought out, such as the methods of implying numbers, algebraic 
signs, etc. Third: the determination of mind-blindness. Fourth: 
emotional and intellectual faculties, which include determination 
of emotion, mentality, etc. Fifth: motor and sensory functions 
should be studied. These should all be critically observed. 




Fig. 47.— Flechsig's Association Areas— Mesial Aspect. 

The definite subheadings, as given by Mills, are as follows : 
The methods of (A) spoken speech should be determined — 

1. Inquiry as to how the patient receives and interprets. 

2. {a) How is it produced? making a record of words, etc. 
(&) Evidence of amnesia and its companionable symptoms — artic- 
ulative amnesia and paraphasia. 

3. How is it repeated or echoed? 
(B) Written Speech — 

1. How is it received and interpreted? 

2. Is sight good, is hemianopsia present ? etc. 

3. How is it produced? 

4. Ask the patient to write his name. 

5. How does the patient write to dictation or from copy? Try 
him in both ways, and if he is able to do either or both, try to 
ascertain if he understands the meaning of what he writes. 



CHAPTER XI 
OTHER DISEASES OF THE BRAIN AND 3IEMBRANES 

GENERAL SYMPTOMATOLOGY 

Theke are certain general signs and symptoms that are found 
more or less constant in almost all organic diseases of the en- 
cephalon. These symptoms may be placed in five classes: (1) 
general symptoms of brain irritation; (2) general symptoms of 
brain pressure; (3) s3miptoms of focal irritation or destruction; 
(4) symptoms due to local pressure; and (5) those due to the 
pathologic process itself. 

The symptoms of brain irritation are headache, vomiting, ver- 
tigo, photophobia, mental irritability, insomnia, a sense of pres- 
sure and fulness- about the head, noises in the ears (tinnitus) or 
in the head, tenderness of the scalp, and in bad cases convulsions, 
paralysis, or delirium and stupor. 

Brain compression has as symptoms headache, vomiting, men- 
tal hebetude or dulness; or it may be some form of paralysis, 
contraction of pupils, and finally coma. Retraction of abdomen 
(scaphoid) accompanied by constipation is often present. 

Symptoms of brain compression may be associated with anas- 
mia, oedema, or increased blood pressure; or, indeed, in states of 
malnutrition, when the brain mass is impoverished, symptoms of 
compression may prevail. Irritation and pressure s3'mptoms may 
interdigitate, so that at times it is impossible to differentiate one 
from the other. Encephalic irritation symptoms are usually asso- 
ciated with hypersemia. 

Focal or local symptoms depend almost absolutely upon the 
location of the lesion causing them. If the motor area is af- 
fected, twitching, spasm, or convulsion would be likely to follow 
early; while when destruction at the same site occurs, the symp- 
toms will be of paralysis. If in a sensory centre or tract, the first 
symptom would be of paresthesia or hyper^esthesia ; the later one 
being of anaesthesia of the part supplied by the centre involved. 

195 



196 TREATISE OIS^ NEEVOUS DISEASES 

Symptoms due directly to the pathologic lesion itself may be 
meagre; just as in tumour of the spinal cord, for example, the 
symptoms of irritation, pressure, or even destruction or local dis- 
turbance of circulation may be dwarfed by septic infection. Gen- 
eral symptoms, the result of septicsemia, such as chill, fever, sweat- 
ing, etc., may become paramount. 

Hemiplegia and aphasia are symptoms that may be caused by 
so many different kinds of lesions that they demand some special 
study here. Both groups of symptoms pertain in general to motor 
or sensori-motor disturbance. 

Hemiplegia is paralysis of one half of the body, as a rule in- 
volving the side opposite the lesion. The arm is usually the most 
palsied, the leg next, and the face least. Hemiplegia may be acute 
or of slow onset, the former being due to haemorrhages, cerebral 
softening, or more rarely to injuries or to inflammations. The 
latter is usually very insidious, and is generally caused by tumours 
or slowly developing areas of sclerosis ; but this may be only a part 
of diffuse sclerosis. The particulars of hemiplegia will be given 
under Special Diseases of the Brain. 

MALFORMATIONS OF THE BRAIN AND ITS 
MEMBRANES 

There is little practical importance to this subject as regards 
congenital malformations, since in most cases the monsters die — a 
most fortunate result. The following are some of the types: 

Brain. — Anencephaly; micrencephaly and microcephaly; por- 
encephaly; malformations or absences (cyclopia). 

Brain and Membranes. — Acrania ; meningocele ; encephalocele ; 
hydrencephalocele. 

With acrania, anenceplialy is always present. In anencephaly, 
the cerebellum and part of the basal ganglia existing may permit 
the child to live for a short time after birth. In micrencephaly 
the brain is but partly developed; and if in addition the cranium 
is also abnormally small, as is generally so, the name microcephaly 
is given. This is due to lack of growth of the brain, and probably 
not at all to premature growing together of the cranial bones, as 
once contended by Yirchow. If the circumference of an adult 
cranium is less than 42 centimetres it will contain a micrencephalic 
brain. Normally the weight of an adult man's brain is 960 



DISEASES OF THE BEAIN AND MEMBEAXES 197 

grammes, while 880 grammes is the weight of an adult woman's 
brain. It is 14 per cent of body weight at birth and 2.4 per 
cent at adult life. Porencephaly is often the result of haemor- 
rhage. In cyclopia there is an undivided anterior cerebral vesicle, 
and the orbits form a continuous cavity with a single rudimentary 
eye. Meningocele is a hernia of the brain membranes. In en- 
cephalocele the brain also protrudes through the cleft in the skull. 




Fig. 48.— Lack of Development. Left Half Cerebrum. (Specimen from 
woman at the Philadelphia Hospital.) 

These forms usually occur in the occipital region and in the me- 
dian line. In hydrencephalocele there is a sac with fluid contents. 



MENINGOCELE 

This may be either of the membranes of the brain or of the 
cord. It consists in the protrusion of the meninges out of the 
natural position within the skull or spinal cord. In the case of the 
brain, where there is also an existent internal hydrocephalus, the 
distended ventricle may form a part of the tumour, in which case 



198 TREATISE ON" NERVOUS DISEASES 

it is then designated a hydrencephalocele. Usually such tumours 
are covered with the skin of the scalp. At other times they are 
devoid of the cutaneous covering. The most frequent position 
for the appearance of these tumours is in the anterior portion 
of the skull, very seldom occurring at the base of the brain. This 
is largely on account of the thinness of bone and the position of 
the fontanelle openings. The hernia is caused by increased cere- 
bral pressure from within, due to excessive fluid, and frequently 
to teratological defects as the primary cause. Adhesion of the 
amnion to the cephalic end of the embryo is probably an impor- 
tant factor in the production of the congenital condition type. 
Disease of the meninges in early life may be the cause of some 
acquired cases. Sex has no influence in their production. Ma- 
ternal impressions and fright are said to be exciting causes of 
these malformations. Usually the length of life in infants affected 
with this deformity does not extend beyond one year. Cases have 
been reported, however, where they reached adult life. 

Symptoms. — Membranes protrude. Drowsiness and mental 
enfeeblement, also paresis and convulsions, are the most impor- 
tant symptoms. 

Pathology. — Usually the condition is an embryological defect. 
If disease of the membranes has been the primary cause, the path- 
ological condition or cause will be that of the primary disease, 
such as meningitis, acquired hydrocephalus, etc. 

Treatment. — This is most uncertain. If the protruding 
<mass is small it may either be excised by the surgeon or com- 
pressed into the cranial vault. Some authorities have advised the 
withdrawal of the fluid in the sac; and where the membrane ex- 
truded is quite isolated from that within the skull, injection of 
carbolic acid, with the hope of setting up subacute inflammation, 
which may shrivel the mass in question, can be tried. 

APOPLEXY (CEREBRAL HvCMORRHAGE) 

By this term is generally understood haemorrhage into some 
part of the brain, and in the majority of instances the bleeding is 
from the lenticulo-striate arteries. These supply nutriment to the 
motor cortex and important ganglia at the base of the brain, from 
which projectile fibres extend to the spinal cord and transfer nerve 
energy to the lower neurons and extremities. 



DISEASES OF THE BRAIX AXD MEMBKAXES 199 

Apoplexy is sometimes called a " stroke/' or '' paralysis '' ; and 
while paralysis is the usual result of a haemorrhage into the central 
nervous system, it is more exact to speak of apoplexy than any of 
the other terms commonly used by the laity. The physician under- 
stands a broader definition of apoplexy even than that above given 
— i. e., thrombosis of cerebral blood-vessels, or embolism, either, 
though more limited, practically produces similiar signs and 
symptoms; the former insidious, the latter sudden. As the treat- 
ment of these three conditions would not much vary, it will be 



Middle cerebral 



Sylvian 

Posterior cere- 
bral 




Anterior cerebral 



Lenticulo optic 



Lenticulo striate 
set of arteries 



Internal carotid 



Basilar 



Vertebral 



Fig. 49.— Showing Arteries at the Base of the Braix. One, the lenticulo- 
striate, is called the artery of cerebral haemorrhage. (Slightly modified from 
Dercum.) 

unnecessary to more than mention them. The predisposing causes 
of true apoplexy are in the following order of occurrence : first, 
chronic alcoholism; second, syphilis; third, other infectious dis- 
eases. The predisposition to cerebral haemorrhage with what 
might be called normal sclerosing or hardening of the vessel walls 
due to advancing years, must be considered; and here it is espe- 
cially that heredity plays an important role in etiology. In pro- 
portion, then, as persons past middle life develop arteriosclerosis, 
will the tendency to this serious malady occur. Induced plethora 
from overeating is a predisposing cause. Physical and mental 
strain are exciting causes. Xight or early morning hours are the 



200 TREATISE OX XERVOUS DISEASES 

most favourable times for cerebral haemorrhage, and especially for 
embolism and thrombosis. Singularly, it often happens when the 
patient has been feeling particularly " well/' although it will be 
found there have been some days or months of sense of vertigo 
with fleeting attacks of congestion of the brain. The attack may 
appear in such a predisposed individual following exertion, strain- 
ing at stool, or after partaking of a hearty meal. 

Signs of Attack. — Rather sudden loss of consciousness pre- 
ceded by thickness of speech, or motor aphasia, accompanied with 
flushing of the face, extreme objective vertigo, followed by falling 




Fig. 50 — Showing the Portions of the Cerebral Hemispheres Supplied, by 
THE Anterior, Middle, and Posterior Cerebral Arteries. (Redrawn 
from Dana. ) 

in unconsciousness if the patient is standing or sitting. AYith 
this there is more or less stertorous breathing, and perhaps clonic 
convulsions will precede the ultimate paralysis, which is usually 
of one side of the body, owing to the location of the haemorrhage 
on the opposite side of the cerebrum. It will be found within a 
half hour that the temperature of the patient has risen slightly, the 
coma becomes more profound, following the marked restlessness 
which is seen just after the stroke. There is slight hj^peraesthesia 
of the paralyzed side, as shown in a few cases where the coma is not 
too profound. The increase of temperature is more pronounced on 
the affected side, and averages half a degree by the axillary record 



DISEASES OF THE BIIAIN AND MEMBRANES 201 

or less by surface thermometers. Hyperpyrexia may rarely occur, 
and is always an unfavourable, usually a fatal sign (Fig. 52). 




The paralyzed extremities when raised from the couch will drop 
flail-like; the patient occasionally, on partial recovery, will, how- 
ever, be able to move the other side of the body. There may also 



202 TREATISE OX XERYOUS DISEASES 

be retention of urine, which mnst be guarded against by the nurse. 
The deep reflexes on the paralyzed side are always diminished or 
absent in this stage. Conjugate deviation of the eyes, or a turn- 
ing of the eyes away from the paralyzed side in cerebral lesions, 
may exist ; or the eyes may remain ^' fixed." If convulsions occur 
the " deviation '' of head and eyes may be towards the palsied side. 

At the end of three or four hours, if the case does not go to a 
fatal issue, the patient begins to improve. The coma now becomes 
less profound, the reflexes appear again in the paralyzed side, the 
patient may recover power in muscles, perhaps an extremity, and 
he may turn from the supine position in which he lay to one or 
the other side. Here the nurse should be instructed as to care to 
prevent pressure paralysis, which may be caused by lying upon the 
enfeebled arm. The chronic stage now sets in. Gradual restora- 
tion of speech takes place in the majority of cases, although there 
may remain some form of dysarthria, as " thickness " of speech, for 
some months in even the most promising cases for large recovery 
of power. There remains difficulty in swallowing, and the saliva 
may dribble from the mouth for some months. As a rule, the 
tongue is protruded towards the paralyzed side and the face drawn 
towards the sound side, although there is no disturbance of taste. 

The muscles of the paralyzed side do not degenerate in the 
sense of showing " reaction of degeneration " by the galvanic 
current, and there is rarely true trophic wasting, only that due to 
disuse of the affected members. In the average case, at the end of 
a few weeks, the patient will be able to move about with the assist- 
ance of crutches or cane. The manner of progression will be typ- 
ically characteristic of the so-called hemiplegic gait. The affected 
limb is thrown out and forward, describing the arc of a circle, and 
then the foot is dropped down flail-like upon the ground. This 
peculiarity in walking is caused by the patient throwing his trunk 
forward and to th^ sound side, due to the fact that the extremity 
being paralyzed, compensatory movements and muscular effort 
must be made by the other limb. Substituting this flaccid hemi- 
plegic gnit. in the course of a few weeks there develops in the 
patient spasticity of the muscles of the affected side ; and then the 
paralyzed member will be, with the partially regained power, 
pushed along in a spastic fashion, the toe being ^^ dug " into the 
ground. 





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20i TREATISE 0:sr XERVOUS DISEASES 

The affected arni^ which has thus far hung flail-like, improves 
more slowly as to power than, does the lower limh; hut with the 
return of power, flexion of the elbows and fingers takes place. 
This is due to secondary contraction of the flexor muscles, which 
are disproportionately increased in power over the extensor group 
of muscles. In the course of the affection there will be found 
secondary degeneration, and this may extend to the opposite side 
of the spinal cord, causing great increase of the deep reflexes on 
both sides of the body. As the case progresses, joint symptoms 
are not unusual; the disuse of the joint and lowered trophic con- 
dition sets up a low grade arthritis, the affected joint becomes 
painful and semi-ankylosed. Subacute neuritis in the affected 
extremity may also be set up. Great wasting of the extremity 
is the exception. There is never reaction of degeneration in the 
paralyzed muscles in cerebral lesions, as already referred to in a 
previous paragraph. Sweating upon the paretic side of the body 
is not a usual symptom, but when present shows vaso-motor 
weakness. The following hygroscopic observation has been made 
for me by Dr. H. E. Wetherill : 

Case of M. K., aged thirty years, female: Right palm, 82.5 
per cent; left palm, 96.0 per cent; abdomen, 2 inches above umbili- 
cus, 84 per cent ; mid-scapular region, Wurtzer's uncovered instru- 
ment, 70 per cent; temperature by the mouth, 98.3° F.. ; tempera- 
ture of the ward, corrected, 72° F. ; relative humidity of air of 
ward, 84 per cent ; barometric pressure, corrected, 30.045 inches. 

Result in this one case : " It would appear that the skin moist- 
ure is increased in the diagnosed condition of left hemiplegia, not- 
withstanding it was a damp day." 

Patliology. — The hasmorrhage is generally due to disease of the 
blood-vessels, which is usually a degenerative arteritis : 

First, attacking the media. Miliary aneurysms form. The 
aneurysms occur most frequently upon the cortical vessels, and 
may also extend to the smallest arterioles. On section of the brain- 
substance they appear as localized, dark bodies about the size -of a 
pin's head. 

Second : Endarteritis and periarteritis may lead to apoplexy, 
either by producing miliary aneurysms or coarse ones of the larger 
vessels, as of the circle of Willis. 

Third: Fatty degeneration of the small vessels occurring in 
purpura, scurvy, leucocythasmia, marasmic conditions, and acute 



DISEASES OF THE BRAIN AND MEMBEANES 205 

infectious diseases. Atheroma is ■asiially found in the larger 
vessels. 

The parts affected in haemorrhage, in the order of frequency, 
are the caudate and lenticular nuclei, meninges and cortex, cen- 
trum ovale, optic thalamus, pons, cerebellum, and medulla. Ven- 
tricular hasmorrhages are usually secondary to haemorrhage into 
the neighbourhood of the basal ganglia. 

After a haemorrhage there is first coagulation of the blood, 
which soon begins to soften and be absorbed. The inflammation 
occurring about the clot usually causes the formation of a fibrinous 
wall around it, which forms a cyst with fluid contents. In other 
cases, instead of the formation of a cyst, there is proliferation of 
connective tissue and the formation of a pigmented scar. 

Secondary degenerations follow, due to the cutting off of nerve- 
fibres from their parent cells, which in most cases, as haemorrhage 
in the region of the internal capsule is very common, would in- 
volve the pyramidal tract and be the cause of late rigidity and in- 
creased reflexes (the inhibitory influence of the cortical cells being 
cut off). 

Diagnosis. — The history of an apoplectic stroke with conse- 
quent hemiplegia is the important point. EmhoJic apoplexy is to 
be diagnosed largely by history of cardiac disease and in the finding 
of a well-marked organic heart disease, as shown by murmur over 
the praecordia. In embolic apoplexy, too, there is not so constantly 
disturbance of consciousness, and the sequent paralysis is very 
apt to be more permanent and localized. Following the embolic 
form also, careful examination may reveal alteration in the phys- 
ical signs of the existent heart disease; for instance, the murmur 
may partially disappear, or at least change in quality very mate- 
rially. In thromhosis there is no positive way of telling, except 
by noting previous history of thrombosis in other parts of the 
body and by extensive arterial degeneration: also of a slow onset. 

Prognosis. — About 50 per cent of cases of apoplexy recover 
from the attack; 75 per cent of these are very apt to have re- 
currence; the remainder go on through life with motor paralysis 
of the parts involved, life being perhaps curtailed, on an average, 
by a decade. The expectancy of life in these cases, therefore, is 
relatively proportionate to the heredity of longevity. 

Treatment and Nursing. — In the apoplectic attack the patient 
should be guarded very carefully, placed in the supine position. 



206 TREATISE ON NERVOUS DISEASES 

with the head partially elevated; ice-caps should be placed to the 
head and hot-water bottles to the feet, being careful not to burn 
the patient, since obtunded sensation by the unconsciousness would 
prevent the appreciation of heat. Friction to the lower extremities 
will aid in restoring circulation here, and thus favour the relief of 
congestion in the brain; or a mustard bath may be of value. A 
denture or other foreign body should be carefully sought for, since 
there would likely be strangulation from this source. It may be 
necessary in some cases to produce traction on the tongue, by means 
of a handkerchief or an artery forceps " clipped ^^ on to the tip 
of the organ. Respiration can also be aided by gentle, firm ele- 
vation of the larynx with the tips of the thumb and index-finger. 
The inhalation of oxygen is a method I have nowhere seen used, 
but it is scientifically ideal for oxidation, and should be tried in 
serious cases when other methods have failed. The revulsant ac- 
tion through the intestinal tract should be brought about by a 
hydragogue cathartic. For this purpose croton oil is employed by 
the physician, 2 to 4 drops being placed upon the tongue directly 
or in solution upon sugar. The reason for this therapeutic meas- 
ure is that the congestion of the mucous membrane causes great 
exudation of serum from the blood, and in consequence of such 
local and general depletion, the marked relief of the congestion in 
the brain. Venesection or bleeding by leeches are important 
adjuncts in sthenic cases. At the end of forty-eight hours small 
quantities of milk may be administered, although for some days 
there should never be excess of nutriment placed in the stomach. 
The patient should be kept warm, with especial attention given, 
however, to ventilation. Stimulants should be eschewed save in 
the use of strychnine, which may be prescribed for heart failure 
only. 

In the " getting up " of the patient, as indicated before, exer- 
cise should be sparingly indulged. The time of sitting up (not 
before a fortnight) should be very gradually increased from day 
to day until there is a proper adjustment of the altered and ham- 
pered circulation. A patient generally has to employ crutches in 
his first endeavour at walking, and this should be encouraged until 
sufficient power has been regained, when the crutches can be substi- 
tuted by a cane. When contractures occur in the paralyzed ex- 
tremities, and even before this to prevent such deformities, it is 
wise to employ massage and stretching in the affected members. 



DISEASES OF THE BHAIN AXD MEMBEANES 207 

The use of iodide of potash is the most valuable remedy at our 
command for the absorption of the exudate in the brain. We 
have seen some excellent results accomplished with this drug, espe- 
cially in the specific cases where the remedy can be gradually 
pushed up to several hundred grains a day. Extra exertion, as in 
lifting, should be guarded against, the bowels must be kept regu- 
lar, and the patient should live a life much less active than usual. 
With this outline, subjects of apoplexy may live many years in 
fairly comfortable health, although hampered considerably as to 
motion and mental capacity. 

Cases of cardiac disease are always more serious, since life is 
menaced by the fact that a vegetation may be carried into the brain 
at any time. 

ENCEPHALITIS 

By this is meant an inflammation of the encephalon or brain 
mass. 

Causes. — The causes of this disease are injuries, infectious dis- 
eases and local infections; or an arterial sclerosis, by cutting off 
nutrition to the cortex of the brain. 

Varieties. — These are acute, as the hemorrhagic; and second- 
ary or chronic, which, is divided into the septic (or brain abscess) 
and the simple chronic encephalitis, which is divided into enceph- 
alitis superior, where the third nuclei are affected, and encephalitis 
inferior, where the cranial nerves below the third are involved. 

Symptoms of Acute Encephalitis. — The symptoms of acute 
haemorrhagic encephalitis are mental confusion, slight rise of tem- 
perature, palsy of the extremities without actual paral3^sis, and but 
seldom convulsions. There may be palsy of the third nerves. The 
disease is very rapid in onset, and may be accompanied by paraly- 
sis of one side of the body (hemiplegia). 

Prognosis. — This is bad, the disease lasting from a few days 
to a week or even ten days, the patient dying of pressure upon the 
brain or from involvement of the respiratory or cardiac centres. 

Pathology. — This consists in an inflammation of the cortical 
cells of the brain with minute haemorrhages scattered here and 
there throughout, and in some cases a distinct haemorrhagic effu- 
sion may exist. There may be optic neuritis, but seldom choking 
of the disk. 



208 TEEATISE OX jSTERVOUS DISEASES 

Symptoms of Chronic Encephalitis. — Symptoms of chronic 
septic encephalitis are all the above symptoms in less severity, plus 
the addition of chills in some cases, and in few a rise of tempera- 
ture, although depression of temperature is frequent even in cases 
of abscess of the brain. There is usually a history of ear disease or 
chronic nasal disease preceding the attack, and with this history 
the case (giving symptoms of inflammation of the brain) will be 
found to be of septic nature. In 90 per cent of all cases sepsis 
will be found. 

There is very frequently localization of the inflammation in 
septic encephalitis, although there may be multiple foci scattered 
throughout the encephalon; if local, such symptoms as convul- 
sions or paralysis may be set up by the irritation or destruction 
through the abscess. Choked disk is not the rule, although optic 
neuritis is likely to occur; and especially is this the case if the 
abscess is cerebellar in origin, which is the most frequent site of 
abscesses, because chronic middle-ear disease is the most frequent 
cause of brain abscess, and the cerebellum being adjacent to the ear 
would explain the prevalence in this locality. If the abscess is .in 
the cerebellum, the cerebellar gait will be a feature in the diagno- 
sis; if in the motor area, convulsions and paralysis would be 
looked for; if in the spheno-temporal lobe, deafness should be 
looked for; or if in the posterior parietal lobe, asteriognosis and 
mind-blindness may be a part of the symptomatology; whereas if 
located in the frontal lobe there are no special symptoms, the men- 
tal stupor, however, being profound. 

Diagnosis. — Differentiation should be made from brain tu- 
mour. This is done by the history of the case and the development 
of irregular temperature in encephalitis and its more rapid 
progress. 

Prognosis. — The growth of brain abscess is usually rapid, the 
patient dying within a few months after its development. It may, 
however, last for 3'ears. and become incarcerated and form a 
^^ cold ^' abscess, which may at any time, from trauma especially, 
develop s3^mptoms of acute septic encephalitis and result in death. 

Treatment. — This is surgical alone. If a case is diagnosed, 
the surgeon should be called into consultation immediately for 
decision as to operation. The best results are obtained in those 
that are cerebral rather than cerebellar, on account of the anatom- 
ical difficulties in the latter. 



DISEASES OF THE BRAIN AXD MEMBRANES 209 

The symptoms of chronic polio-encephalitis superior are those 
of simple encephalitis of mild type. There is no pain connected 
with the disease, and the third nerve being involved, we have in 
addition ptosis, exophthalmos, and iridoplegia. The eyes are also 
held in external strabismus if the sixth nerve is still intact. 

The symptoms of polio-encephalitic inferior are those of ordi- 
nary encephalitis, plus those of the involvement of the nuclei of 
the fourth and the cranial nerves below this. If the pathetic alone 
is involved there would be, in addition to the above symptoms, 
rotation of the eyes up and in. There is an absence of tempera- 
ture in cases of chronic nature. According to the nerves involved 
below the fourth nerve, will we have symptoms of paresis of those 
nerves. 

Prognosis is very unfavourable. Some amelioration may be ex- 
pected under thorough treatment. 

Diagnosis. — It should not be confused or confounded with 
any other form of disease, the particular point being preservation 
of consciousness with the incomplete palsies suggested above. 

Treatment. — This is palliative; quiet is essential; apply cold 
to the head, and use supportive measures, such as strychnine and 
belladonna in small doses, or of nitroglycerine, to support the 
heart. Iodides should be used, as also sorbefacients where there 
are any symptoms indicating exudates about the inflammatory 
area. Individual galvanization of muscles of paralyzed parts, 
such as of the eye muscles, may be of some value. These patients 
may live for a long time — years; however, they are very likely to 
be carried off by an intercurrent affection, as pneumonia. 

BRAIN TUMOUR OR CEREBRAL NEOPLASM 

This occurs in the majority of instances in early adult life, 
depending somewhat on the nature of the growth, which are in 
the order given: tuberculoma, fibroma, sarcoma, glioma, carcino- 
ma, and gumma, the first and last being really deposits of the spe- 
cific granulomata. The tubercular tumour is more frequent in 
childhood, the gumma occurring between twenty and forty, and 
sarcoma at about thirty years of age, whereas carcinoma is apt to 
develop after forty years of age. 

Brain tumours are in many cases distinctly hereditary, perhaps 
in 50 per cent of the cases. This fact has helped the writer in 
14 



210 TREATISE ON NERVOUS DISEASES 

the diagnoses of obscure cases, which, put with the weight of other 
evidence, will always be of service. 

Symptoms. — These are of two kinds: (1) general, and (2) spe- 
cial, local, or focal symptoms. 

The general symptom^s consist in mental excitement, vomiting, 
^o-called reflex or cerebral vomiting, vertigo, choked disk and 
headache, the latter being of a dull character. The choked disk is 
present in between 90 to 95 per cent of cases, and is usually more 
intense in cerebellar lesion. It is much more frequent in neoplasm 
than in other organic affections within the cranium. The vomit- 
ing mentioned comes on without cause, being not accompanied by 
nausea, nor is it particularly related to the ingestion of food. It 
is designated re-flex or cerebral or central vomiting. 

Special local or focal symptoms are of importance in deter- 
mining the location of the growth. If it be located in the frontal 
lobe, there will very likely be undue mental apathy, unless the tu- 
mour itself produces much irritation or protrudes into the orbital 
cavities, where, of course, ordinary methods of diagnosis will de- 
termine. The peculiar incoherency of mind in frontal-lobe disease 
is a symptom, if taken in conjunction with other signs of tumour, 
that is of great value. Keen has laid great stress upon tenderness 
over the site of the tumour. This is of value only in cortical 
growths, where it may be a distinct help. 

If the tumour be localized in the motor cortex of the brain, 
there will be convulsions, focal in character, due to the location 
of the tumour, and later in its growth paralysis of the same parts 
will follow. 

If the tumour be located in the parietal region, sensory 
changes maybe found associated probably with mind-blindness or 
asteriognosis, depending upon the location of the growth. 

A tumour in the temporo-sphenoidal lobe would produce word- 
deafness. 

A tumour in Broca's region would produce motor aphasia. 

A tumour located in the corpus striatum would produce a pare- 
sis of the opposite side without convulsions, and likely disturb- 
ances of temperature, due to the involvement of the centre for heat 
regulation within the striatum. 

A tumour in the optic thalamus would produce hemianopsia, 
and within the anterior part the Wernicke pupillary inaction symp- 
tom ; whereas, if posterior to the thalamus, the centre for pupil 



DISEASES OF THE BRAIN AND MEMBRANES 211 

contraction not being involved, we would not have the symptom 
present accompanying the lateral homonymous hemianopsia. 

A tumour in the corpus callosum will produce symptoms simi- 
lar to subcortical tumours from which they cannot be distin- 
guished. 

A tumour in the cerebellum produces a most marked choking 
of the disk, is typical, and in addition there is titubating gait, with 
other evidences of ataxia, frequently manifested in the hands, as 
athetosis. Knee-jerk would be vacillating and early increased. 
Later it may disappear, mostly in cases involving the middle lobe. 

Gyrus XTncinatus. — Tumour here will produce perversion of 
sense of smell — anosmia, hyperosmia if involving the olfactory 
bulb or nerve. 

Gyrus Fornicatus. — Tumour in this region will be evidenced 
by a loss of sense of smell. 

Cuneus. — Tumour will produce, when located in this region, 
mind-blindness and hemianopsia without the Wernicke sign. 

Sensation of taste may be disturbed when the tumour reaches 
the centre of the glosso-pharyngeal and facial nerves (chorda 
tympani). 

Tumours of the meninges will cause a greater amount of pain 
than if the growths develop in the brain structure, since the sen- 
sory nerves are in the dura, and are therefore irritated. 

PatJiology of Brain Tumours. — This will entirely depend upon 
the nature of the growth, whatever that may be. There is always 
found about the neoplasm a subacute inflammatory process with 
round-cell infiltration and more or less serous exudate. The brain 
is apt to become oedematous from interference with the circula- 
tion. These points should be particularly remembered, since they 
give rise to sj^mptoms which are necessary in the diagnosis of the 
case. In a case of Weir Mitchell's, the localization of the tumour 
was confirmed by autopsy, although the localizing symptoms were 
entirely masked in the later course of the affection by the circula- 
tory disturbances already referred to. 

Diagnosis. — This is a difficult matter indeed. The principal 
disease to be confused with it is abscess, where the history of 
septic process about the cranium will be an important point to 
be taken into consideration. The excursion of temperature above 
or below normal will also assist in the diagnosis. Chronic men- 
ingitis and sinusitis from the pain alone are likely to be confused 



^12 TREATISE OK NERVOUS DISEASES 

with tumour, but are wanting in localizing symptoms, and in the 
intensity of the choked disk seen in tumour. 

Prognosis. — This is bad, but 7 per cent of the cases are oper- 
able, and just this per cent has a chance of recovery. 

Treatment. — Beyond surgical there is little to be done; med- 
ical treatment is simply palliative, such as in the use of iodides, 
mercury, or other alteratives. Hygienic guarding of the patient 
is essential above that of all other brain affections. Pain must be 
controlled by morphia. A pill of camphor monobromate, gr. iij, 
often affords relief. 



CHAPTER XII 

INFLAMMATIONS OF THE MEMBRANES OF THE CORD 
AND UNCLASSIFIED DISEASES 

External pachymeningitis involving the dura mater ; internal meningitis in- 
volving the dura mater ; leptomeningitis involving the pia mater ; hyper- 
trophic pachymeningitis involving both dura and pia. 

Inflammations of the Dura (Pachymeningitis). — a. Pachymen- 
ingitis externa is a secondary inflammation, but is occasionally 
met in the acute form following caries, tumours, aneurysms, or 
syphilitic affections of bones. An abscess may penetrate the spi- 
nal cord, or the inflammation may be set up in the peridural 
tissue in long-standing cases of decubitus, pachymeningitis re- 
sulting. 

Symptoms. — These are usually those of compression myelitis. 
The chronic form of external pachymeningitis is most commonly 
secondary to tuberculous disease of the spine (see Myelitis in 
Pott's Disease, Chapter X) ; hence the vertebral disease is impor- 
tant in the production of symptoms. This form is apt to be local- 
ized to the site of Pott's disease. The internal surface of the 
dura may be perfectly smooth and in some cases but slightly ad- 
herent to the arachnoid. The external surface is rough and cov- 
ered with a cheesy substance. In some cases this material is 
chiefly anterior to, and in other cases it completely surrounds the 
cord. 

1). PacJiymeningitis interna is usually found located in the cer- 
vical region. The space between the cord and the dura is occu- 
pied by a form of concentrically arranged fibres, developing within 
the dura, and not on the outside at all. The condition is similar 
to hsemorrhagic pachymeningitis interna of the brain. The cord 
is usually compressed, the central canal dilated (hydromyelus), 
and there are secondary degenerations. The nerve-T-oots are in- 

213 



214 



TREATISE ON NERVOUS DISEASES 



Yolved in the growths and are damaged and compressed. The 
disease is chronic and may be limited to one segment, or in the 

greater number of cases 
it actuall}^ involves a con- 
siderable portion of the 
cervical enlargement. 

Symptoms. — Intense 
pains along the nerves 
whose roots are involved 
are present. There may 
be hypersesthesia or anaes- 
thesia with numbness and 
atroph}^ of the interossei, 
hypothenar and thenar 
groups. The arms be- 
come weak, the extensors 
may remain intact while 
the flexors are affected, 
producing the so-called 




claw-hand 



main 



en 



griffe. At times the sec- 
ond stage also, of the 
French, consisting of in- 
volvement of the lower ex- 
tremities and introduction 
of spastic paral3^sis, may 
supervene several months 
later, due to secondary de- 
generation in the cord. 
The disease runs a chronic 
course, lasting two or more 
years. In a few instances 
in which symptoms point- 
ed definitely to this condi- 
tion recovery took place, 
and I have no doubt that not a few cases of amyotrophic lateral 
sclerosis that have been reported much improved by several observ- 
ers are cases of pachymeningitis interna with complete absorption 
of exudate. 

Diagnosis. — (a) The external form is diagnosed by the con- 



FiG. 53.— Chronic Cervical Tubercular 
External Pachymeningitis. (Specimen 
from case of complete diplegia in the Phila- 
delphia Hospital.) 

(a) Site of tubercular deposit at site of kyphosis ; 
{b) Cauda. 



IXFLAMMATIOX OF MEMBRANES OF CORD 215 

currence of Pott's disease, the absence of atrophy of muscles, 
and the usual seat being in the dorso-lumbar region of the cord. 
(b) The internal type is diagnosed first from amyotrophic lat- 
eral sclerosis by the fact that severe pain does not occur in the 
latter ; from syringomyelia by the absence of sensory changes char- 
acteristic of gliosis ; and from tumours by the more localized symp- 
toms in neoplasm. 

Prognosis. — This is to be guarded, since some of the most 
marked cases have been greatly improved to the surprise of the 
neurologist. Given a case in Avhich the disease has been stayed 
with physical health of the patient maintained, and where great 
contractures or atrophy of the part has not occurred, the prog- 
nosis may be guardedly given as favourable to partial restoration 
of the health, at least. Acute fulminating cases from the begin- 
ning usually end in the death of the patient.- Even in cases that 
have apparently recovered any undue exertion or exposure to heat 
is apt to cause recrudescence. Treatment of either form is the 
same as for that of other types of. meningeal inflammation. 

LEPTOMENINGITIS 

This is a condition closely allied to pachymeningitis physio- 
logically, although pathologically pachymeningitis consists of in- 
flammation of the pia. Practically these inflammations are asso- 
ciated more or less in every case. Leptomeningitis is more likely 
to be acute or fulminating, due to the fact that it is, as a rule, 
a septic type of inflammation, and also is resident in the larger 
blood-vessels of the pia associated more intimately with the nerv- 
ous system. For this reason, even although the inflammation be 
not so severe, serious symptoms would result. The difference in 
the symptomatology between leptomeningitis and pachymenin- 
gitis would consist largely in the fulminating character of the for- 
mer, accompanied by much less pain in the back or over the site of 
inflammation, for the reason that the sensory roots are less im- 
pinged upon: but there is greater paralysis in the parts below 
site of lesion, and also the greater liability to decubitus. Lepto- 
meningitis is seldom a chronic disease, hence there are no special 
symptoms described for the latter, since that would be clinically 
the same in all respects as pachymeningitis chronica. 

Prognosis. — This is uncertain. It will depend largely upon the 



216 



TREATISE OX NERVOUS DISEASES 



degree of infection and the extent of involvement of the cord. 
Where there is early involvement of the multipolar nerve-cells 
there is nsnally decubitus, accompanied by great palsy and disturb- 
ance of the bladder as well as of the rectum, the patient usually 
succumbing within a few days. Such cases rarely recover without 
chronic myelitis and paraplegia being the result of the leptomen- 
ingitis. 




Fig 04.— ATKOPHY of L^TTEKOSSEI, ThENAK and HVPOTmi^AK MUsCI^ES of liOTH 

Hands ; (also of Shoulder Girdle and Pectoral Muscles) in a case of 
Infectious Pachymeningitis Cervicalis Hypertrophica. (Medico-Chirur- 
gical Hospital.) 



Hypertropliic pachymeningitis involves both pia and dura. 
It is usually septic in origin. The gonococcus may be the organ- 
ism acting as exciting cause, as in the case imder our care shown 
in the illustration (Fig. 54). 

.Treatment of Pachymeningitis and Leptomeningitis. — This 
consists of absolute rest in bed in a quiet, darkened room, the appli- 
cation of ice to the spine, and the use of counter-irritants, such as 



UNCLASSIFIED DISEASES 217 

strong tincture of iodine over the site of the inflammation, of blis- 
ters, or the actual cautery, repeatedly applied, in chronic cases. In 
the acute form general antiphlogistic measures may be necessary, 
such as cold sponging or the cold pack ; or by antipyretic drugs cau- 
tiously used, such as phenacetine and antipyrine. It may be neces- 
sary to give small doses of morphine to control the pain. If there 
are convulsions, the use of bromides and chloral, mixed, in fairly 
large doses, will be indicated. A lo-per-cent ointment of soluble 
metallic silver used by inunction in dram doses is a valuable rem- 
edy in septic cases. In chronic cases, if conTulsions persist admin- 
ister ether for their control. If contractures follow, orthopaedic 
treatment may be necessary, such as tenotomy or extension of the 
contracted limbs. This, of course, shoukl be resorted to after it 
is evident that massage and Swedish movements prove of no avail. 
The use of potassium iodide is valuable as a remedy in chronic 
cases for the absorption of the exudate. This drug should be 
pushed to its physiological limit and continued for many weeks. 
In cases of paraplegia, resulting from pressure of exudate or 
actual inflammation through extension from the pia to the cord, 
the Treatment will be that of the existent sequent myelitis. 



CAISSON DISEASE 

Synonym: Divers disease 

This is a disease with marked nervous manifestations, induced 
by the long submergence of the body in air at high pressure. It is 
doubtful if the affection would develop, until very late at least, 
were the body kept in a gradually increased atmospheric pressure. 
. Etiology. — As indicated above, the affection is caused by the 
sudden change from increased to decreased pressure of the atmos- 
phere. It is probably due to the enfeebled vaso-motor nervous sys- 
tem. Divers are particularly subject to this, hence the name of 
diver's paralysis. The pressure that will induce diver's paralysis 
must be more than three atmospheres. 

Symptoms. — It is characterized by a paraplegia, less frequently 
general palsy, appearing on returning from the compressed to the 
surface atmospheric pressure. These symptoms are more likely 
to develop on rapid change from the high to the ordinary atmos- 
pheric pressure. They may supervene shortly after leaving the 



218 TREATISE ON NERVOUS DISEASES 

caisson or may be several hours in their development. In the 
mildest forms there are pains about the knees, which are often of 
great severity. Abdominal pain and vomiting are not uncommon. 
The muscles may be tender to the touch and the patient walk in a 
spastic fashion. Accompanying the other neurologic symptoms 
there is dizziness and intense headache, which later may, however, 
occur without vertigo. In the severer forms we may find com- 
plete motor and sensory paraplegia, a monoplegia or hemiplegia 
being rare. The most extreme attacks resemble apoplexy; pro- 
found coma, and death rapidly supervenes within a few hours. 

Prognosis.- — In cases of paraplegia the outlook is usually good. 
The palsy may pass off within a day or may continue for several 
months. 

Pathology. — This is indefinite, although it is probably a 
vaso-motor disturbance in the simple cases that recover. In th6 
severer cases there have been found, as in the case of Leyden, 
foci of haemorrhages and evidence of acute myelitis. Fissuring of 
the cord sometimes occurs, some authorities believing it to be a 
constant phenomenon. It has been suggested that this condition is 
due to the freeing of nitrogen within the cord, the element having 
been absorbed by the blood under high pressure. 

Treatment. — The patient should be kept quiet. Pain must 
be controlled by analgesics, such as morphine, etc. Inhalations 
of oxygen and the use of compressed air has been advised. Paral- 
ysis should be treated as any other form of palsy of similar type. 
As a prophylactic measure divers should pass gradually into the 
compressed-air chamber. According to A. H. Smith, at least five 
minutes should be allowed for each additional atmospheric pres- 
sure. Another prophylactic measure consists in bringing the 
patient very slowly into the normal atmosphere; as we have indi- 
cated should be the case in entering the compressed-air chamber. 
Ergot is a remedy which may control the vaso-motor nerves in 
cases where there is paralysis of vaso-constrictors. It should be 
given hypodermically in half-dram doses. Bandaging of the limbs 
has also been advised. 



UNCLASSIFIED DISEASES 219 

LANDRY'S DISEASE (ACUTE ASCENDING 
PARALYSIS) 

This is a disease probably of toxic nature, more frequent in 
males, and coming on in cool weather in the greater number of 
cases, as though the temperature had something to do with its pro- 
duction. It is in all probability due to an autocthonous poison. 

Symptoms. — A case of Landry's disease, or ascending palsy, 
if it be typical, consists of a fulminating onset of paralysis, begin- 
ning in the lower extremities, and ascending rapidly to the trunk 
and upper extremities, the head muscles escaping. It usually 
occurs between twenty and thirty years of age. The symptoms are 
frequently preceded by moderately high temperature. N"ausea 
occurs, but gastro-intestinal disturbance is not a particularly nota- 
ble feature of the disease. There is a sense of paraesthesia, to a 
slight degree only, in the extremities, but no other distinct sen- 
sory disturbances. While the reflexes are absent there is no ten- 
derness of nerve-trunks and no 'involvement of the sphincters of 
the bladder or of the rectum. The patient is almost completely 
paralyzed, as above described, within seventy-two hours after the 
onset of the disease, and may not be able to move a muscle below 
the head; the chest expansion being very little, cardiac rhythm 
irregular, sometimes very rapid (tach3Tardia) ; the respiration 
being carried on entirely by the diaphragm through the phrenic 
nerves. The external respiratory nerve coming off lower down 
from the cord being affected, leaves the motor function of respira- 
tion alone to the phrenic nerve. Involvement of the pneumogas- 
tric nerve frequently occurs, which is another serious cause of em- 
barrassed respiration, heart action, and cord function. This is 
often the cause of the sudden death which usually supervenes at 
the end of a week or ten days. There have been no cases recorded, 
such as those described, that recovered without leaving some dis- 
turbance or serious alteration of the nervous sj-stem as a sequelse. 
A case under the writer's care may be referred to, where the man 
is to-day the subject of chronic muscular atrophy with main en 
griffe or claw-hand. So that cases that do recover are generally 
those where the symptoms will have been proved to be the result of 
some definite lesion, and not those in which the pathology has not 
as yet been understood or discovered. In some instances the 
paralysis may be descending in its initiation and sequent course. 



220 TEEATISE ON NERVOUS DISEASES 

Diagnosis is therefore as between this disease and multiple 
neuritis, if any difference at all exists, the only point being that 
the eases that have recovered present signs of multiple neuritis or 
involvement of the cord. The fatal cases, through the rapidity 
of their courses, do not develop pathologic changes that are demon- 
strable by modern microscopic technique. 

Prognosis. — This should be put down as absolutely fatal. 

Pathology. — In some cases diffuse myelitis or neuritis has 
been found. In others, the majority, no lesion has been detected. 
In one reported by the writer (Journal of Nervous and Mental 
Diseases, January, 1893), a multiple neuritis is the real cause of 
the clinical picture. Of course, these cases are taken out of the 
realm of Landry's palsy per se, but the clinical picture may be 
identical. A typical case of Landry's palsy consists of no definite 
lesion; nor does the patient develop trophic changes, such as bed- 
sores. 

Treatment. — This consists in supporting the patient by means 
of strychnine hypodermically, or by transfusion of blood by hypo- 
dermoclysis of normal salt solution, in order to counteract the con- 
dition of the blood, which is undoubtedly toxic. The \ise of 
galvanism to encourage respiration and cardiac tone would be of 
importance in the cases where these functions are particularly 
hampered. Eectal nourishment is a procedure which will be of 
value, since any attempt to give food per or em might excite dan- 
gerous symptoms of respiratory or cardiac failure. If the case 
should survive, the after-treatment would be as indicated in 
chronic neuritis or myelitis — i. e., massage, galvanism, alterative 
drugs, as iodide of potassium or the so-called Donovan's solution, 
the liquor arsenii et hydrargyri iodidi (a 1-per-cent solution), 
given in 3- to 5-minim doses thrice daily. We know of no better 
alterative remedy in chronic non-specific inflammatory states than 
this drug. The use of crutches may be necessary to get the patient 
about. In all chronic palsies we wish to again urge getting the 
patient into action soon, since use stimulates function; otherwise 
hysteria may soon become a part of the clinical picture. 



CHAPTER XIII 
DISEASES OF THE SPINAL CORD 

MALFORMATIONS OF THE SPINAL CORD-SYSTEM 

DISEASES 

{General considerations) 

There are some thirty diseases of the spinal cord. The ma- 
jority are organic and come under the head of inflammations and 
of degenerations or system diseases. Organic diseases the result 
of injury and inflammations are most common. Functional dis- 
eases of the cord alone are rare, such as the so-called " irritable 
spine/' which latter, too, is associated with general functional dis- 
eases, as hysteria. 

Etiology. — Most causes come under injury, auto-intoxications, 
poisons from without, exposure, infectious diseases, and excess 
of functionation. Middle-aged persons are more liable to these 
affections. Heredity may play a part in the predisposition due to 
vulnerable nerve-tissue. 

Symptoms. — These all come under the head of irritation, de- 
pression, and of perversion. Irritative symptoms consist of pains, 
paraesthesias, hypersesthesias, and feelings of constriction around 
the waist, rigidity, spasms, exaggerated reflexes, and irritability 
of the visceral and vascular functions. The symptoms of de- 
pression are those of anaesthesia, ataxia, palsies, wasting, and 
loss of control of viscera, as of the bladder. In cord disease para- 
plegia is the common form of palsy. Symptoms of irritability 
and depression often accompany each other. The more super- 
ficial, the more irritative signs exist; the more central, the more 
paralysis and visceral weakness prevail. In meningitis and men- 
ingeal affections there is much pain, and vice versa, as to cord 
diseases per se. 

Pathology. — Inflammation of the cord membranes is not un- 
common; but primary inflammation of the cord itself is unusual, 
> 221 



322 TREATISE ON NERVOUS DISEASES 

since most of the diseases that used to be called myelitis are sec- 
ondary to injuries and softenings. Tabes and progressive muscu- 
lar atrophy are given as " system diseases " by most writers, be- 
cause they affect certain long-fibre tracts or groups of cells; but 
this name implies too many restrictions, hence it is retained only 
as a matter of convenience. Secondary degenerations alone are sys- 
temic. The cord is not infrequently the seat of abscesses, haemor- 
rhages, or tumours. 

Diagnosis. — In making a diagnosis of cord diseases help comes 
through a thorough knowledge of cord functions. Physiology and 
anatomy point out the signs and symptoms more clearly than in 
any other part of the body. (See Chapter I.) 

Prognosis. — Spinal-cord tissue once destroyed can never be 
renewed to more than a very limited extent. This regeneration 
applies to the nerve-fibres, not the cells. The diseased cord fre- 
quently adjusts itself to the pathological damage; but again, in- 
jury is very likely to extend by the process of secondary degen- 
eration so rapidly that compensatory function cannot take place. 

The special diseases of the cord are as follows: 

(1) Malformations'. Myocele, meningo-myelocele (spina 
bifida), meningocele, heteropia, amyelia, micromyelia, macrom}^- 
elia, double cord. 

(2) Vascular disorders: Anaemia, hypersemia, haemorrhage, 
endarteritis with aneurysm, embolism, thrombosis, oedema. Sec- 
ondary to these conditions are softenings, myelomalacia, and scle- 
rosis. 

(3) Inflammations : Meningitis, myelitis, abscess. Also sec- 
ondary softening and sclerosis. 

(4) Degenerations: Primary: Locomotor ataxia, combined 
scleroses, hereditary scleroses, progressive muscular atrophy, and 
similar affections. 

(5) Syphilis: Meningo-myelitis, gumma, single or multiple, 
and specific endarteritis* 

(6) Tuberculosis: Miliary and solitary. 

(7) Tumours. 

(8) Functional and toxic disorders. 



DISEASES OF THE SPINAL CORD 223 

MALFORMATIONS 

Spina Bifida {Rhachischisis Posterior) 

This is a congenital hernia of the spinal membranes, sometimes 
of the cord, through a cleft in the vertebra caused by absence of 
the vertebral arches. It is therefore more of a malformation of 
the vertebral canal rather than of the cord, although this is not 
always so, for the -cord and its membranes may be found in a con- 
dition of agenesis at the site of canal malformation. 

Etiology. — About 1 in 1,200 children are thus affected (French 
statistics). It may be associated with hydrocephalus or with 
some other defect of development, such as imperforate anus or 
pharynx, or of ventral hernia. Heredity may be a factor in its 
causation. It is not due to dropsy of the cord, but is a true 
malformation. It is more common in males. 

Varieties. — There are three forms described: 

(1) Spinal meningocele is a condition in which the spinal 
membranes alone protrude into the sac. 

(2) Spinal meningo-myelocele is a form in which the mem- 
branes and cord both pass into the sac. 

(3) Syringo-myelocele (hydrorhachis interna) is a form in 
which the fluid is in the central spinal canal and the inner lining 
of the sac is formed by the meninges and thinned-out spinal cord. 

Anatomy. — The most common are the first two types, which 
are called hydrorhachis externa. The fluid lies in the subarach- 
noid space, hence the wall of the protruding cyst is lined with the 
dura and arachnoid. The nerves and cord protrude into the sac 
in two thirds of the cases, forming a meningo-myelocele, but in 
some only a few nerves are found. When protruding into the 
sac they lie on the posterior and median surface, being attached 
and forming part of the wall; hence the spinal nerves start from 
the wall of the sac and go back into the vertebral canal. Be- 
sides the above-noted contents the tumour contains fat and con- 
nective tissue. The external surface is often red, flattened out, 
and smooth, and there is sometimes a depression on its median 
surface where the cord is attached. 

Symptoms. — Spina bifida generally occurs in the lumbar and 
sacral regions, since the laminse here are the last to solidify. But 
two or three vertebrae are usually involved. The tumour varies 
from 1 inch to 6 or 7 inches in diameter. It mav be sessile or 



2U TEEATISE ON NERVOUS DISEASES 

be pedunculated. The outer skin is often glossy, or tough, thick- 
ened, or ulcerated. 

Children with spina bifida are usually very poorly nourished 
or inherently feeble, and as a rule poorly developed mentally. In 
over 50 per cent of the cases paraplegia is found associated more 
or less with ansesthesia or involvement of the sphincter muscles. 
Contractions and contractures may occur, causing various phases 
of acquired talipes. 

Prognosis is grave, being best for meningocele. The patient 
may live in such cases to early adult life, but injury or infection 
may occur, and the patient be carried off by secondary myelitis. 

Diagnosis is fairly certain. Usually it is only necessary to 
exclude congenital tumours which happen to be located in the 
lumbo-sacral region. The most important question to decide is 
whether the cord and nerves are present in the sac, which is 
very probable if there is much paralysis, anaesthesia, or sphinc- 
ter trouble, or if there is a depression on the median external 
surface. The passing of an aseptic insulated needle connected 
with a galvanic battery may be tried in a difficult case. 

Treatment is entirely surgical, and of avail only in menin- 
gocele. At present injections of Morton's fluid (iodine, gr. x; 
potas. iodid., gr. xxx; glycerin, §j), in dram doses, seem to be 
the most successful. These injections should be made on the 
outer portion of the sac, the child being kept on the back. Com- 
pression is dangerous if the fluid has been previously withdrawn. 
Opening the sac, excising, or ligaturing are most dangerous, 
especially if part of the cord should happen to be in the sac. In 
skilled hands surgical results have recently been more favour- 
able. Operation should not be done within the first four months 
of life. 

MENINGOCELE OF THE CORD 

Meningocele of the cord is protrusion of some or a portion of 
the membranes of the cord from the canal. It usually occurs in 
the infant, being a congenital defect of closure of the neural canal, 
the bones and membranes themselves being involved. . In some 
cases the cord itself protrudes. 

Symptoms. — No symptoms exist except the physical signs of 
protrusion of the tumour (which is usually in the lower lumbar, 
or in the sacral region of the cord) until at some later period in 



DISEASES OF THE SPINAL CORD 



225 



life injury to tliis mass sets up an inflammation, when- the symp- 
toms of spinal meningitis and paraplegia will follow. The worst 
cases, due to the defect of the nervous system as well, will pre- 
sent typical signs and symptoms of paraplegia, with contractures, 
loss of sensation, involvement of the sphincters, bedsores, etc. 

Prognosis. — This will depend upon the degree of defect and 
the condition of the patient. More cases may pass through life 
undisturbed, but the existence of a tumour about the sacral re- 




FiG. 55.— Agenesis and Micromtelia. of Spinal Cord in a Male aged Forty 
Years ; also Lack of Development of the Acoustic Nervous Centres. 
(Philadelphia Hospital. ) 



gion is always a menace to life. Cases with paraplegia at birth 
will be very apt to succumb within a few months to a year. 

Treatment. — As in cases of spinal meningocele, treatment 
would be mainly surgical, if at all. This consists in compression 
and protection of the part. Eemoving the protruding mass, or the 
injection of carbolic acid or some other irritant into the tumour 
mass, with the hope of causing its disappearance, should of course 
only be done in selected cases. 

Heteropia is a rare malformation wherein masses of gray mat- 
ter are found in abnormal positions. Van Gieson describes a false 
heteropia that may be caused by manipulation of the cord after 
death, in which case the displaced masses consist of nerve-cells 
or neuroglia. 

Amyelia, or absence of the spinal cord, can exist only when 
15 



22G TEEATISE OX NERVOUS DISEASES 

the brain is absent, although absence of the brain may occur 
without absence of the cord. In amyelia the spinal nerves are usu- 
ally present. Amyelic monsters cannot live. 

Double cord is very rare, and involves only a part of the cord 
except in cases where there is a double vertebral canal. 

Double central canal is not rare. It usually is found in only 
a part of the cord, and the two canals lie parallel. 

Asymmetry of the cord, usually due to abnormality in the 
course of the pyramidal tracts, is not so rare. 

Splitting of the cord and defects in development at special 
levels are found occasionally. 

Agenesis implies lack of proper development of the cord. (Fig. 
55.) 

Micromyelia is a condition in which the cord is abnormally 
short or is small in size. The normal cord varies in diameter 
from 6 to 9 millimetres (dorsal), 8 to 11 millimetres (upper 
cervical), 15 millimetres (cervical), and 12 millimetres (lumbar). 

SYSTEM DISEASES 

By reference to the chapter on Anatomy will be found the 
division of the spinal cord into certain tracts or systems. A 
degenerative disease of these tracts is frequently confined to one 
or may- extend to two tracts. The first is designated a simple sys- 
tem disease, and the second is styled combined system disease. 
Both the peripheral and central motor neurons may be involved, 
singly or together. 

LOCOMOTOR ATAXIA 

{Tabes dorsalis; posterior spinal sclerosis) 

Locomotor ataxia is a system disease, affecting the afferent or 
sensory tracts of the cord. 

It is divided into the following stages : 

1. Preataxic. 

2. Ataxic. 

3. Paralytic. 

The prominent symptoms, as its name indicates, are ataxia, 
inco-ordination of gait, sensory disturbances, loss of reflexes; also 
accompanied by atrophic disturbances and impairment of the spe- 
cial senses. In tabes the bones are brittle. 

The symptoms confined to the preataxic stage are of shoot- 



DISEASES OF THE SPINAL CORD 227 

ing pains, coining on at irregular intervals, and usually in the legs, 
and principally in the calves. The patient may complain of a 
sense of numbness in the extremities, and may or may not have a 
sensation of constriction about the body, which is called the girdle- 
sense, or, if painful, it is called the " girdle-pain." The patient 
even now may develop the perversion of sensation, as of some- 
thing soft, when really walking on a hard surface like a pave- 
ment. At times there may be violent paroxysms of pain referred 
to certain internal' viscera, the so-called " gastric crisis " being the 
most important and frequent one. This pain is located in the epi- 
gastric region, and is accompanied by vomiting and excessive secre- 
tion of the gastric juice. The attack may last from a few moments 
to an hour or so. In severe attacks the prolonged weakness follow- 
ing may exist from one to several days. The sexual power is gener- 
ally decreased in this stage, although the appetite is frequently in- 
creased. There may be difficulty in urination. Upon examination 
of the eye, the so-called Argyll-Robertson pupil may be determined 
— this consisting of a lack of response of the iris to light stimulus, 
although accommodation reaction is preserved. In some rare cases 
there may even begin optic atrophy in this stage of the disease. 

Ataxic Stage. — This is the stage when the patient usually is 
seen by the physician, from the fact that he does not report for 
treatment until inco-ordination of gait actually sets in ; or fre- 
quently from lack of diagnostic acumen of the physician the disor- 
der is not made out until this stage is reached. It is characterized 
by the ataxic gait, which consists in throwing the limbs forward, 
outward, and downward in an irregular and lax fashion, the heel 
descending first. The gait is more ataxic when the patient's eyes 
are closed or when he is walking in the dark. Since the cause of 
this symptom is the perversion or diminution of the muscular 
sense, the explanation of a better locomotion in the light or with 
the eyes open lies in the fact that the eyesight makes up for the im- 
paired muscular sense. Another symptom present and dependent 
upon the same disorder of co-ordination is the Romberg's sign, 
which consists of marked swaying of the individual, the feet being 
in the position of attention. The sway is more pronounced so soon 
as the eyes are closed. Other evidences of inco-ordination are 
shown in muscular movements generally, and particularly in these 
finer movements, as of the fingers, the patient being unable to 
write properly, the letters being slowly and irregularly outlined. 



228 



TEEATISE ON XEEVO-US DISEASES 



If the index-fingers of opposite hands are brought together there 
will be found to be great inco-ordination as they approach each 
other^ or if brought to the nose the same phenomenon will be 
observed; this sign being also exaggerated by the patient clos- 
ing his eyes. A variety 
of ataxia called static 
ataxia, frequently exist- 
ing, is detected by hav- 
ing the patient lie on 
his back, then elevating 
the legs from the bed in 
a fixed position. If in- 
co-ordination exists the 
patient is said to have 
static ataxia. Or it is 
tested for by the patient 
standing erect, eyes 
closed. If he sways badly, 
he also has static ataxia. 
The latter is the Eomberg 
sign, as indicated above. 

In this stage there 
generally is an aggression 
of all the other symptoms 
mentioned, though in the 
minority of cases the 
painful sensations become 
abated, and paraesthesia 
will become lessened or 
disappear in them. The 
patient loses his vigour, and there is usually muscular wasting and 
weakness, in spite of preservation of the digestive function. It 
will be found in 50 per cent of the cases that the optic nerves 
degenerate, this being a primary optic atrophy and not accom- 
panied by the choked disk of optic neuritis. The ataxic stage may 
last for many years, and during that time periods of exacerbation 
and remission of the symptoms occur, out of proportion appar- 
ently to the extent of lesion. This irregularity in such cases must 
be due to loss of nutrition for the time being, rather than to 
organic change in the cord. 




Fig. 56.— Standing Posture, Static Ataxia 
IN Tabes Dorsalis. (Philadelphia Hospital. ) 



DISEASES OF THE SPIXAL CORD 229 

Paralytic Stage. — This comes on very late in the course of the 
disease, and signifies nmscular paralysis, associated with signs of 
paresis. In this stage the patient becomes bedridden; develops 
more or less atypical paresis or progressive paralysis of the insane. 
A very small per cent of cases reach this stage, since they are 
iisTially carried off by some intercurrent malady. The absence of 
the deep reflexes determined so early in the preataxic stage re- 
main persistently absent during the entire course of the disease. 
In some cases optic atrophy is an early symptom, and is so rapid 
in its onset and progress that this class of cases is given a dis- 
tinctive name, the so-called amblyopic form of tabes. In these 
cases it is frequent to find the ataxia held in some subjection or 
actually bettered with the onset of blindness. This is marked in 
a coloured man in my wards at the Philadelphia Hospital, where 
on becoming totally blind the ataxia is much lessened; so with the 
crises from which he suffered up to that time. Other cases of 
tabes may develop unusual symptoms, such as perforating ulcer 
of the foot, which is a very rare condition, occurring in not more 
than two per cent of the cases. There is a typical case of this 
complication in ataxia, a man, aged forty, now in the paralytic 
stage of the disease, at the Philadelphia Hospital, a description 
of which ulcer will be typical of the condition. The ulcer extends 
from the base of the great toe on the sole of the foot, over the ball, 
is much indurated, but signs of inflammation are very slight; the 
nutrition of the surrounding tissue being at a low stage. The ulcer 
is sharply cut, -J by f of an inch in diameter, and extends down to 
the depth of f of an inch by a central sinus which leads down to 
the metatarsal bone. There is also a foul odour emanating from 
the sore, with considerable sanious discharge therefrom. It is not 
at all painful. 

Another unusual development in tabes is the arthropatliy, 
which consists in enlargement of the joint, generally a large one, 
as the knee, due to a subacute trophic inflammation. The bones 
become porous, the synovial membrane lustreless or entirely dis- 
appears, the ligaments of the joints becoming so relaxed as to 
permit of easy dislocation. Synovial fluid occurs in excess early, 
but may later be absorbed, leaving a much relaxed joint. These 
joints are not painful, and only give disturbances by the enlarge- 
ment and weakness entailed. The h3'potonia of the muscles about 
the affected joint exaggerates the deformity. (Fig. 57.) 




Fig. 57.— Charcot Joints (Right Knee and Both Ankles) in Tabes. 
(Medico-Chirurgical Hospital. ) 



DISEASES OF THE SPIXAL CORD 231 

The characteristic feature of all_ cases of tabes is the dispro- 
portionate increase of inco-ordination to the small amount of 
muscular weakness per se and wasting; so that in some cases the 
patient will show very good strength of muscle when the ataxia 
is pronounced. Absence of the Argyll-Robertson pupil, the other 
symptoms being present usually, but rarely occurs. 

Other unusual symptoms are the areas of ansesthesia, which 
are generally irregular in outline, and are situated upon the chest, 
over the shoulder girdle, or upon the upper arm, and disobey the 
anatomical rules in that they do not follow the nerve-trunks, nor 
apparently the segments of the cord in all cases. 

The duration of tabes will be on an average from three to 
thirty years. The disease is much more frequent in males, occur- 
ring at about thirty years in an average case. 

Etiology. — It is a parasyphilitic infection in over 90 per cent 
of cases, usually occurring from eight to fifteen years after the 
initial lesion; other causes being overwork, auto-intoxications, or 
chronic poisonings, such as of malaria, of which I have seen one 
case in a young man eighteen years of age. 

Pathology. — The pathology of tabes consists in sclerosis of 
the posterior columns of the spinal cord and the nerve-roots. The 
columns of Clarke and Burdach are particularly involved. The 
spinal ganglia and roots are frequently affected. The peripheral 
nerves are occasionally diseased. The pia mater between the pos- 
terior roots is thickened and opaque, the posterior roots being 
enlarged, while in advanced cases they become thinner and more 
translucent. The spinal cord is reduced in size, and the poste- 
rior columns appear to be shrunken and present a grayish ap- 
pearance. The first sclerotic areas, as a rule, are found in the 
posterior roots, usually in the lumbar region and in the tract 
of Lissauer; next the columns of Burdach are affected, beginning 
along the median side of the posterior horns, spreading out 
towards the posterior median saeptum, finally involving, as in- 
ferred, the column of Goll ; and may ascend to the upper thoracic 
and cervical regions, the usual seat of lesion being confined to the 
lumbar cord. The fine fibers running from the posterior roots to 
the column of Clarke are also sclerosed, but the cells then are not 
usually destroyed, and consequently the direct cerebellar tract is 
rarely degenerated. 

Diagnosis. — Tabes should not be confused with any other dis- 



232 TREATISE OX XERYOrS DISEASES 

ease, save possibly sj^ingomyelia, where the dissociation of sensa- 
tion in the latter and mnscular atrophies would be distinguishing 
points. Chronic multiple neuritis, with ataxia, w^ould be deter- 
mined by the muscular atrophy again; also by tenderness over the 
inflamed nerves, so that in studying a given case the presence of 
shooting pains, absence of knee-jerks, the presence of Argyll-Rob- 
ertson pupil with or without optic atrophy, and history of syphilis, 
there would be very little doubt as to tabes being present. There 
is increase of knee-jerks in ataxic paraplegia. 

Prognosis. — While complete recovery rarely occurs, much can 
be done, however, to ameliorate the symptoms and to lengthen the 
period before the paralytic stage should occur. Ten years is an 
average duration. 

Treatment. — In an early case usually antisyphilitic measures 
are indicated, since it is possible that some remnants of the patho- 
logical exudate of the third stage of syphilis should exist, which 
the use of the iodides and mercury by the sorbefacient and altera- 
tive action may tend to dissipate. Prolonged active antisyphilitic 
treatment should not be carried on after it is noted that distinct 
improvement has not occurred. In debilitated cases a combination 
of cod-liver oil with the alterative drugs, as arsenic, should be em- 
ployed. In anaemic persons the use of iron is indicated. If after 
a thorough trial benefit is not had, some of the following drugs 
may be used until the one is determined that particularly benefits 
the case. Arsenic given in the form of Donovan's solution, 4 drops 
t. i. d. ; or the chloride of gold and sodium, ^ gr. t. i. d. ; and the 
glycero-phosphate of lime or soda. Long-continued dOses of sil- 
ver nitrate, i gr. t. i. d., have been found efficacious by some ob- 
servers. Strychnine mav be resorted to in cases where there is 
much weakness, although, as a rule, strychnine is not an ideal 
drug, often making the patient irritable and exaggerating his 
ataxia on account of muscle stimulation. In addition to drugs 
the patient should be instructed to abstain from alcohol, tobacco, 
and sexual indulgence, and he should have plenty of nutritious 
proteid food, fresh air, and sunshine. The overuse of the lower ex- 
tremities, as in a half -hour's walk, is baneful. Exercises should be 
rather of a passive nature ; hence the ideal treatment for a case of 
tabes is the "rest cure," plus the use of massage and Swedish 
movements by an experienced manipulator. In mild cases, where 
the patient is going about, the method first introduced by Weir 



DISEASES OF THE SPINAL CORD 233 

Mitchell and later amplified by Frankel is important. This con- 
sists in a series of educational movements, the patient lying on his 
back and approximating his toes and his fingers together, etc.; 
finally walking along a crack in the floor and stepping over 
bricks placed upon the floor, with the eyes opened, then closed. 
As the patient improves he is instructed to do more difficult exer- 
cises, such as walking backward under the same conditions. 

Warm sponge baths given at night are valuable in the relief of 
pain, and by the stimulation of secretion to the carrying off tox- 
ines from the system. The warm bath (temperature of 150° F.) 
must not last longer than fifteen minutes, and should be followed 
by a cold spray down the spine for two or three minutes, the tem- 
perature of the water being about 60° F. The entire procedure 
thus far should be followed by a brisk rub with a Turkish towel, 
in order to stimulate the superficial circulation, and thereby to 
relieve congestion about the posterior roots of the spinal cord. 
Another measure not used sufficiently for the relief of tabes, and 
especially the painful cases, is to resort to high altitudes, above 
5,000 feet, in a dry climate. Such cases I have seen benefited in 
Colorado and New Mexico. 

Suspension treatment is a valuable measure also in some cases 
to relieve pain. It consists in suspension of the patient by lift- 
ing the body to the tip-toes by means of a head-piece about the chin 
and occiput and under the elbows. The seance should last three 
to five minutes once or twice a week. It relieves pain by stretch- 
ing the spinal ligaments and aiding circulation about the nerve- 
roots. 

Drugs to relieve pain should be only used with great precaution 
for fear that the patient may form the drug habit. Antipyrine 
can be given in 5-grain doses; a combination of the analgesics 
with codeine, s "to i grain, is frequently very valuable ; a h^^poder- 
mic injection of morphine, i to ^ grain, guarded by atropine, ^g-o 
of a grain, must be given to control crises. To relieve the tingling 
and numbness of the legs static electricity administered thrice 
weekly is good treatment; but more particularly is the use of the 
Faradic " dry brush " an excellent procedure in these cases. Coun- 
ter-irritation by blister or cautery over the lumbar spine at times 
acts remarkably well in alleviation of painful paroxysms. 

Of great importance is the nutritive state of the patient, 
which should be carefully watched at all times even to the holding 



234 TREATISE OX XERVOUS DISEASES 

in abeyance all other treatment, since if nutrition is not pre- 
served improvement will not take place. Red meats, eggs, oysters, 
cereals, good bread and butter and milk, in as large quantities as 
the patient is able to digest, are the ideal foodstuffs that should be 
employed. 



DISEASES OF THE MOTOR NEURONS OF THE 
SPINAL CORD 

Primary Lateral Sclerosis 

This is a disease characterized by a paralysis of the muscles, 
beginning usually in the lower extremities, and attended with in- 
creased reflexes, but unattended by muscular atrophy or sensory 
disturbances. This disease occurs most frequently between the 
ages of twenty and forty. It may appear earlier, as reported in a 
case by H. X. Moyer in a child of five years. I have seen for some 
years a case with Sinkler, reported by that gentleman and myself 
in a paper on family diseases, already referred to. In this case — a 
woman about thirty-eight years of age — the disease began about 
twenty years ago, and has been very slow in progress. Some cases 
have been supposed to follow syphilitic infection, or to be caused 
again by hereditary syphilis or alcoholism transmitted from the 
parents. Others have appeared to be due to traumatism to the 
back, or to exposure to cold and wet, and to certain infectious dis- 
eases; or to excesses, predisposing to general physical debility 
through excessive drain on the nervous system. 

Symptoms.— The patient first complains of rigidity with 
weakness of the muscles of the lower extremities, which may be 
associated with a sense of fatigue or dull pains, but never of an 
active character. The symptoms may first commence in one leg 
before the other is at all affected, or one may be affected more 
than the other. The loss of power is very gradual and not at all 
in proportion (as in ataxia) to the impairment of progression, 
which in this instance is due to spasticity. The extremity soon 
becomes rigid, so that on flexing the joint a sensation as of bend- 
ing a piece of lead pipe is transmitted to the examiner. If the 
movement is continued the rigidity lessens. The gait in the very 
beginning is slightly spastic, as shown by the patient wearing the 
shoes out at the toes or complaining of tripping over slight impedi- 



Df^EASES OF THE SPINAL CORD 235 

ments. Later the characteristic spastic gait prevails, and the 
feet appear glued to the ground and are pushed forward with 
effort. The toes are raised over obstacles with great difficulty. 
Voluntary effort increases the clonic and tonic spasms of the mus- 
cles, and owing to spasm of the adductor and stronger muscles the 
knees are kept close together, and in aggravated cases there is 
often cross-legged progression. The knee-jerks are markedly in- 
creased and ankle clonus well developed, although not so large as 
in cases of insular (or disseminated) sclerosis. The superficial re- 
flexes are slightly increased. Muscles are not wasted, excepting 
that resulting from disuse. They feel firm to the touch. The 
sphincters are not involved until very late in the course of the dis- 
ease. Sensory disturbances are absent, other than paraesthesia, the 
result of circulatory disturbances from vaso-motor weakness. The 
upper extremities do not become involved until late in the course 
of the disease. Seldom do trophic ulcerations occur, but the affect- 
ed extremities are very easily frost-bitten. The patient may live 
many years in comparative comfort, other than the physical dis- 
tress of being thus disabled from active life. 

Pathology. — This consists in a degeneration in the pyramidal 
tracts. That this may occur primarily is not definitely settled, and 
many observers believe that degeneration of the pyramidal tracts 
alone cannot occur, except as a secondary degeneration due to 
lesion higher up. A few cases have been reported, however, in 
which no such primary lesion could be found. 

Diagnosis. — In transverse myelitis sensory symptoms are more 
pronounced, the disease is more acute, anaesthesia frequent, and the 
sphincters are early affected. In ataxic paraplegia the spasticity of 
the muscles is not so marked and evidence of lack of co-ordina- 
tion is present; involvement of the sphincter is also common. In 
amyotrophic lateral sclerosis there is muscular atrophy, not noted 
in the disease under consideration. Secondary degeneration fol- 
lowing cerebral apoplexy may rarely be mistaken for cases of pri- 
mary lateral sclerosis, in which one side is more affected than the 
other. The history of a previous apoplexy would, of course, settle 
the question. Hysterical paraplegia may quite often be difficult to 
distinguish. In lateral sclerosis rigidity of limbs is more pro- 
nounced when they are extended, and vice versa, a condition that 
does not occur in hysteria. Also the deep reflexes, while they may 
be increased, are not so much so in hysteria, True ankle clonus 



236 TREATISE ON NEEYOUS DISEASES 

is exceedingly rare in the disease under consideration. Other 
evidences will also be f onnd, snch as '^ stigmata " or hysterical 
paroxysms, which are more frequent, too, in females. 

Prognosis. — The prognosis of the disease is steadily slowly 
onward and downward until the power of progression is lost. The 
patient may live for twenty or thirty years, and die as the result 
of an intercurrent disease, although involvement of the bulb may 
through inhibition of the vagus cause death from heart fail- 
ure. 

Treatment. — This is not very satisfactory. Nitrate of silver, 
chloride of gold and sodium, iodide of potassium, etc., may be 
of service. Massage is a valuable agent in arresting muscular 
wasting. The electric brush is also of use in stimulating the cir- 
culation. The patient should be well fed, given the hypophosphites 
from time to time, and must be well protected with woollen cloth- 
ing. Strychnine is contra-indicated, as it excites the muscular 
spasms in already irritable muscle fibres. 

SPASTIC SPINAL PARALYSIS 

Spastic Paralysis 

This term applies to a form of paraplegia caused by (a) chronic 
myelitis, as well as to a (b) congenital disorder in which there is 
sclerosis of the lateral columns of the cord. There has been 
much controversy as to the latter, some giving the name of Lit- 
tle's disease to the diplegic or paraplegic forms of the cerebral pal- 
sies of childhood, though, properly speaking, this should be ap- 
plied to lateral sclerosis. Little first described the condition in 
1846 and in 1877. In 1873 and in 1879 Dr. E. C. Seguin, of 
New York, described a condition of similar type which he called 
" tetanoid paraplegia." Erb and Charcot in France independ- 
ently in 1875 published articles on " spasmodic spinal paralysis '' 
and " spasmodic dorsal tabes " respectively. After this there was 
much confusion. Finally, the spastic paralysis has been shown 
to be due to spinal, associated probably with cerebral defect. 

Etiology. — It is congenital and due to lack of development of 
the pyramidal tracts, which leads to a sclerosis of the lateral col- 
umns and to symptoms of spasticity of legs and arms, exaggerated 
reflexes, with some weakness, and at times slight atrophy. Pre- 
natal or natal in its origin, it is primarily an agenesis in the first 



DISEASES OF THE SPIXAL CORD 237 

instance; or if caused at birth, as Little supposed, may be due to 
premature or forced deliveries. It may be a family disease. 

Symptoms appear shortly after birth, usually within a year, 
but may appear after the fifth year in family types, or even 
after maturity. There is a type of this disease I have seen vrhere 
the spasticity remains entirely in the lower extremities, coming on 
at about fifteen years of age, and not affecting the upper extremi- 
ties at all. In the ordinarr type it is, as inferred, difficult to dis- 
tinguish spastic spinal paralysis from the cerebral palsies (or 
" birth. palsies," so called). The lack of marked mental impair- 
ment is a point in differentiation, the brain seeming to be spared 
except for its motor areas being damaged. At times, too, lateral 
sclerosis cases occasionally gain in development, and some in- 
crease in the use of the limbs follows more than in cerebral palsies. 
The so-called '^ scissor-legs '' frequently are found in these pa- 
tients, the crossing of the limbs being exaggerated in the efforts of 
walking. The arms are much less affected than the legs. The 
throat and facial muscles may be slightly involved. In some cases 
the disability increases quite rapidly. There is no pain, however. 
The arms may later be contractured. Finally the patient becomes 
helpless. Epilepsy or mental deterioration may develop at the 
time of puberty or adolescence. 

Prognosis. — The mild cases that learn how to walk should be 
kept carefully at the practice of their muscles, when they may 
slowly improve and reach average health and adult age. Severe 
cases rarely reach adolescence, and generally die of some inter- 
current disease before the twenty-first year of age. 

Diagnosis. — It is distinguished from the cerebral (or birth) 
palsies by the absence of any material initial mental defect, micro- 
cephalus, or of epilepsy. From compression myelitis spastic paral- 
ysis is distinguished by the affection of the arms, the absence 
of pain, and of disturbance of the sphincters. Hereditary spastic 
palsy, which is also found to occur in families, begins later (at 
about the fifth year, see p. 238), and involves the legs chiefly. 

Treatment consists in orthopaedics, massage, and Swedish move- 
ments to prevent contractures and deformities. General nutri- 
tion must be carefully maintained : also the protection of the body 
from cold or extremes of temperature. Employment of tenotomy 
mav be necessitated where mechanical treatment fails, in which case 



238 TREATISE OX XERVOUS DISEASES 

braces should be applied to retain the normal position of the 
limbs, and the child then encouraged to walk about by means of the 
wheel crutch or other form of apparatus. Many cases have been 
improved so as to walk with some facility by persistence in this 
regard, and a hopeless life of invalidism stayed. 

HEREDITARY SPASTIC SPINAL PARALYSIS ^ 

This disease is of the family type, affecting different members 
of succeeding generations. It begins about the age of five, affects 
mainly the legs, runs a very slow course, is not accompanied by 
pain, ataxia, or visceral symptoms, and may continue for thirty 
years or more. The writer has two cases of this rare affection 
under observation where there seems to be a remission of all 
symptoms within the last six months. 

FRIEDREICH'S DISEASE, OR HEREDITARY ATAXIA 

This is a developmental disease, occurring in early youth, is 
more frequently met with in males than in females, and the symp- 
toms very frequently begin at about the tenth 3'ear, the patient 
having been in apparent good health up to that time, although 
undoubtedly of vulnerable nerve protoplasm. There may be found 
a history of heredity, although the affection is never congenital ; or 
there will be a history of syphilis or alcoholism in the progenitors, 
usually in the parents. 

Symptoms. — These consist first in ataxia, very much like that 
of tabes, but accompanied by irregular choreiform movements, 
perhaps athetosis, as in a case reported by Swan and myself 
(Philadelphia Medical Journal, January, 1896). The speech is 
frequently affected in this disease, staccato-like and drawling, 
accompanied by dribbling of saliva from the mouth, inability to 
masticate food properly, and by dysphagia. The mental condition 
remains fairly good, although one is apt, from the mechanical de- 
fects, to appear feeble-minded, a condition similar to the pseudo- 
imbecility in some cases of spastic paralysis of childhood, where 
mental failure is exaggerated by the fact that the vocal muscles are 

^ In all these so-called spinal spastic paralyses occurring in early life there 
must be some cerebral defect or agenesis, though the degeneration is largely 
associated with the lateral tracts of the spinal cord. 



DISEASES OF THE SPINAL CORD 230 

spastic. The Argyll-Robertson pupil is not so constant as in 
tabes dorsalis, but there is often present nystagmus, usually bilat- 
eral. The knee-jerks are not constantly absent, though usually so, 
and may change from year to year in accordance with the in- 
volvement of the posterior columns, lateral columns, or anterior 
horns of the cord in varying degrees, and thus disturbing the 
physiological reaction of these parts as the disease picture 
changes. The patient may also develop club-feet — the equino- 
varus position being particularly common — due to contraction of 
the posterior leg muscles. Localized muscle atrophy is in evi- 
dence, and where this occurs fibrillary twitchings will also be 
found. Curvature of the spine is another symptom that may 
exist, dependent upon muscular weakness of the erector spinse 
group. Trophic joints are very rare indeed. Paraesthesia may 
exist.. In Marie's cerebral type cerebellar gait exists. 

Pathology. — This consists in an overgrowth of neuroglia 
cells within the central nervous system, particularly involving the 
posterior roots and posterior columns of the spinal cord. In 
addition round-cell infiltration may be present in other parts of 
the cord about the anterior horns and in areas diffused through- 
out the brain. It is undoubtedly the remnant of an embryological 
defect in the child, which by the developmental period first gives 
expression to symptoms, just as syringomyelia gives rise to symp- 
toms due to a gliosis commencing in prenatal life from defect in 
the embryo itself. 

Diagnosis. — This disease should not be confounded with any 
other. Diagnosis may lie between it and spastic paralysis of child- 
hood, which latter presenting increase of reflexes in the spastic 
condition with more marked athetosis and lack of atrophies, would 
be sufficient signs for the proper diagnosis of this disease. Insular 
sclerosis is told by the more pronounced nystagmus, increase of 
reflexes and its later development. From tabes, the earlier devel- 
opment of Friedreich's disease, the lack of crises, and the type of 
movements (choreic) will make it clear. 

Prognosis. — The patient may live for many years, but usually 
does not reach maturity. 

Treatment. — This is solely palliative, and consists in proper 
nutrition ; hygiene, as to clothing and exercise, which latter should 
be limited, though systematic, and particularly in the form of 



240 TEEATISE ON NERVOUS DISEASES 

calistheiiics towards preventing contractions; for which massage 
and Swedish movements are also valuable agents. Drugs, sueli as 
potassium iodide, in small continuous dosage, also the chloride of 
gold and soda, ^^-^ gr. t. i. d., and in atonic cases the use of strych- 
nine will be of great service. For the prevention of deformities, 
or where they exist already, the use of a " brace " may be necessary 
to the spinal column or to the lower extremities, and in some cases 
the use of crutches will be of value in permitting the patient to 
move about. These subjects are very liable to. become bedridden, 
so that educational movements should be faithfully tried. 

CEREBELLAR ATAXIA 

This is also an hereditary disease, and begins later in life than 
Friedreich's disease — from fifteen to eighteen years of age. 

Symptoms. — It is particularly characterized by the cerebellar 
or titubating gait added to tl;e other symptoms of ataxia. The 
.knee-jerks are increased, diminished, or precocious in this dis- 
ease, but there is seldom found ankle clonus. The duration 
of the affection may be for many 5^ears (eight or ten), the 
patient generally dying of some intercurrent affection. Club- 
feet are very apt to develop, due to contractions, the gait being 
somewhat similar to that of ataxic paraplegia. The patient pre- 
sents no sensory symptoms. 

Pathology. — This consists in degeneration of cells of Purkinje 
in the cerebellum and the posterior columns of the spinal cord. 
Atrophy of the optic nerve may exist and nystagmus may be 
present. 

Treatment. — This is symptomatic. The use of the hypophos- 
phites and nutritional measures with calisthenics and Swedish 
movements as described under the previous disease. For the pre- 
vention of deformities of the legs braces should be applied by the 
orthopaedic surgeon. 

FUNCTIONAL DISORDERS OF THE SPINAL CORD 

Functional disorders of the spinal cord include those of irrita- 
tion or of depression coming under the head of spinal neurasthenia, 
or spinal irritation, or spinal exhaustion. These symptoms are 
described under the head of Neurasthenia (see Chapter XVI). 



DISEASES OE THE SPINAL CORD 



241 



CAUDA EQUINA 

The Cauda equina is made up of five lumbar, from five sacral 
and one coccygeal (Miiller), nerve-roots. They lie within the 
dura, extending beyond the spinal cord some 15 centimetres. 
These distinct motor and 
sensory roots do not quite 
unite until they pass out 
of the dura. The cauda 
begins at the lower edge 
of the second lumbar ver- 
tebra. The term conus is 
applied to the part of the 
cord below the second 
sacral segment. In this 
part (conus) the anterior 
root-fibres are smaller and 
fewer in number than the 
posterior or sensory root- 
fibres. Miiller gives the 
arrangement of the vis- 
ceral centres as follows : 
Second sacral, erection 
centre; third sacral, ejac- 
ulation centre ; fourth 
sacral, bladder (detrusor) 
centre; fifth sacral, sphinc- 
ter ani centre. 

. Symptoms and Diag- 
nosis. — The diagnosis of 
Cauda lesions involves a 
study of: 

1. Lesions of the lower 
end of the cord. 

2. Cauda compression, irritation, or destruction. 

3. Lesions of the peripheral nerves; 

1. Lesions of the lower end of the cord generally come on rap- 
idly, in a few days, following myelitis, etc. There is little pain, 

and dissociation of sensation comes on late. 
16 




Fig. 58.— TuMorR (Psammoma) springing 
FROM Dura, Lower Dorsal Cord. 
(Specimen from Philadelphia Hospital.) 



M2 TREATISE OX XERYOUS DISEASES 

Fibrillary contractions and involuntary twitchings of the leg 

muscles occur. Paralysis rapidly appears, involving the lower 

■ limbs in accordance with the segmental distribution of the nerves. 

It is a flaccid palsy and is followed by atrophy. The visceral cen- 
tres are involved. If the conus is not implicated the paralysis 
does not seriously involve these centres nor the muscles of the 
pelvic girdle. The motor symptoms are far more prominent than 
sensory symptoms. The cord being small is easily destroyed, and 
very little improvement ever occurs. 

2. In disease of the cauda, since it is usually a neoplasm, the 
symptoms generally come on slowly. In injury the symptoms 
appear rapidly after the trauma. There is often severe pain in the 
Ijladder. in the sciatic distribution, and it is bilateral. Anaes- 
thesia in the area of the sciatic nerves follows later. The paraly- 
sis is slow in development. The sensory symptoms are far more 
prominent than the motor at all times. The sexual bladder and 
rectal centres are later paralyzed. Sometimes prompt operation, 
as in tumour, will give quick relief. This should always be done 
where tumour is suspected, otherwise the case is hopeless as to 
cure. The symptoms in compression of the cauda without de- 
struction are like compression of the cord, but there is less motor 
disturbance, and there may be no involvement of the sphincters. 

3. Lesions of the peripheral nerves (neuritis or injury) is 
rapid in onset. There are sciatic pains — tender spots along the 
nerve-trunks. The lesion may be only unilateral, the pain being 
not so severe, and there is no m.arked anaesthesia. There is little 
or no paralysis of the visceral centres, the sensory slightly pre- 
dominating. There is often a history of sciatica or alcoholisni or 
injury. Examination may disclose the presence of a tumour or of 
some disease affecting directly the sciatic plexus : and the prog- 
nosis is favourable. 



CHAPTER XIY 
DIFFUSE AXD FOCAL DISEASES OF THE SPIXAL CORD 

SPINAL HYPEREMIA, ACUTE AND CHRONIC 

JJiioJogy. — Violent physical exertion, sexual excesses, amenor- 
rlioea, and certain poisons, as strychnine, are causes of spinal 
hypersemia. It is also the first stage of acute inflammatory dis- 
eases. Chronic spinal liypercemia is rare. It may occur in the 
membranes as the result of meningitis or injury. There is no 
absolute knowledge of separate chronic hypera?mia of the cord. 

Symptoms are of a sense of weight around the loins, of heavi- 
ness, twitching of the muscles, a numbness, formications, and 
actual pain of a neuralgic nature, accompanied by numbness of 
the lower extremities. The sphincters may be involved. The 
symptoms are as inferred, usually confined to the lower extremi- 
ties. The position of the patient, as mentioned by some authors, 
can have but little influence upon symptoms due to spinal hyper- 
gemia. The signs and symptoms of chronic spinal hypersemia are 
much like those of spinal irritation. They will be described 
under that head. 

Pathology. — The circulation of the blood in the spinal cord, 
as has been shown in the chapter on Anatomy, is one which is diffi- 
cult to distttrb ; but if so, it is slow in being brought back to nor- 
mal. The violent activity of the heart and great increase in arte- 
rial pressure, and then the weakened state of the heart muscle and 
lowered tension, appear to modify but little the spinal functions. 
Hence it is unlikely that the large number of clinical symptoms 
that have been attributed to the circulatory failure are so caused. 

Treatment. — This consists in the application of cups to the 
back, rest in the horizontal position, better upon the side or face, 
counter-irritation to the spine, or the use of cold, as in the form 
of ice-bags. Among drugs the employment of bromides and mor- 
phine is good treatment. The sorbefacient and alterative effect of 

243 



244 TEEATISE ON NEEVOUS DISEASES 

chloride of ammonium and the iodides is recommended; or the use 
of galvanic electricity, the negative pole being placed over the 
spine and the positive at some indifferent point (5 minutes). 

SPINAL ANEMIA 

Spinal anaemia is less known in its cause, symptomatology, 
and course than is hypersemia. It is more apt to affect the 
posterior columns than the ventral aspect of the cord, for the 
reason that the dorsal nutritive arteries are smaller than the an- 
terior ones. Severe haemorrhages or extreme diarrhoeas may be 
predisposing factors by causing general anaemia. Or aortic obstruc- 
tion, as in aneurysm, may be the cause (through cutting off blood 
supply to the cord) of almost total abolition of cord function. It 
is not common for serious disturbance of the cord to persist from 
anaemia excepting where there is disease of the arteries, and in that 
event the sclerosis of the posterior columns may follow in the wake 
of an added pernicious anaemia, in which latter the general symp- 
toms overshadow those of the spinal cord. The test of the patient's 
improvement when lying on his back is perhaps incorrect. Some 
writers associate with spinal anaemia a class of symptoms such 
as pain in the back and weakness of the legs, which may amount to 
paraplegia, a group of symptoms that has been given the name 
of spinal concussion, but it is impossible to scientifically state 
whether spinal anaemia is the underlying condition in such cases. 

SPINAL HEMORRHAGE 

Spinal Apoplexy 

This general name may be given to (1) haematorrhachis or 
spinal meningeal haemorrhage, and (2) haematomyelia or haem- 
orrhage into the cord substance. 

(1) Spinal mening-eal hsemorrhage is the most usual form, and 
may be extradural or intradural. Extradural haemorrhage is the 
more usual disease. 

Etiology. — It is more common in men than in women. It 
also occurs in newly born children. Falls, injuries, and fractures 
of the spine are the most usual causes. Convulsive seizures due to 
epilepsy, tetanus, chorea, eclampsia, or strychnine may cause it, 
the same as in severe muscular strain. The various dyscrasiae fol- 



DISEASES OF THE SPINAL CORD 245 

lowing infectious diseases, such as purpura, may cause it ; or it may 
be due to the bursting of an adjacent aneurysm, such as of the 
aorta or vertebral artery, and in very rare instances cerebro-spinal 
meningitis. 

Symptoms. — There may be no ascertainable symptoms in 
minute hemorrhages. In large haemorrhage there is sudden se- 
vere pain in the back, shooting down the limbs, associated with 
numbness, hyperaesthesia, muscular spasm, generally of the back 
muscles; later, paresis, paralysis, and anaesthesia may follow, with 
disorder of the visceral centres. The disease is fulminating, 
reaching its acme in the course of a few hours. Remission may 
then occur, accompanied by slow recovery or followed by chronic 
meningitis. Death may occur very early from exhaustion. 

Diagnosis. — Injur}^, or childbirth followed by the sudden onset 
of attack, with irritative symptoms, as pain, which suddenly sub- 
side, point to extradural haemorrhage. In haematomyelia there 
is less pain and irritation, but more marked paralysis and anaes- 
thesia. This is also true of crush of the cord from fracture or 
dislocation. In tetanus the symptoms are more gradual in onset 
and trismus is present. 

Prognosis. — If the patient survives beyond the fifth day there 
is a chance for partial or complete recovery. Usually the prog- 
nosis is most grave, the patient succumbing within a few days. 

Treatment consists of absolute rest in bed, administration of 
sedatives and drugs to move the bowels and relieve pain. Local de- 
pletion may be tried, as by means of wet cups over the supposed 
site of lesion. The use of styptics, as suprarenal extract or min- 
eral acids, may be of service in the purpuric cases. The sorbe- 
facient effect of the iodides may be tried later; also the use of 
mercury. In chronic cases counter-irritation over the spine on 
alternate days for a fortnight may prove of value by its alterative 
action. 

(2) Haematomyelia. — Haemorrhage into the substance of the 
cord. 

etiology. — This is not unusual. It may be due to vascular 
diseases or purpura h^emorrhagica, or may be secondary to tumours 
or to myelitis. Primary haemorrhage occasionally occurs in in- 
fancy, but it is usually found in males in early adult life. Accord- 
ing to Gowers, excessive coitus is a potent cause, as are injuries, ex- 
posure, overexertion, syphilitic endarteritis, or convulsive seizures. 



24:6 ■ TEEATISE ON NERVOUS DISEASES 

which latter may also be the cause of haemorrhage into the skin and 
intermuscular connective tissue. Haematomyelia may occur in old 
people with arteriosclerosis^ spinal apoplexy being produced, in- 
stead of cerebral haemorrhage. 

Symptoms develop rapidly, with numbness or weakness for a 
few hours. Then sudden paraplegia, or ataxia, or both. Often 
the anaesthesia is dissociated — there being a loss of pain or ther- 
mic sense, with the retention of touch sense. The urine may 
have to be drawn on account of paralysis of the sphincters. The 
reflexes may at first be absent, but soon return and become exag- 
gerated. There is much pain in the back, and if the lesion is 
high up the anus and thorax are involved. The acute symptoms 
will have subsided within a fortnight, when the case becomes 
practically one of chronic myelitis. If improvement has not oc- 
curred, the symptoms will instead take on the character of acute 
myelitis, and death will soon follow. 

Pathology. — The blood-vessels diseased are those of the gray 
matter, which are in the ventral cord and under considerable ten- 
sion. The rupture of these vessels is due to fatty degeneration 
or to specific endarteritis. Miliary aneurysms are rare in the cord, 
such as not infrequently develop in the brain. Haemorrhage may 
be the cause or the result of a myelitis. In the former case the 
clot lay be absorbed, leaving a cavity as in the cord; or broken- 
do^, tissue may become the central foci of a myelitis. The haemor- 
rhag. is usually single ; it may be multiple. It is likely that cases 
of d sseminated myelitis following infectious fevers are due to 
mull pie ecchymoses. The bleeding at times is the result of new 
grov th, as in syringomyelia. 

diagnosis. — Sudden onset without any long premonitory 
symptoms and the absence of fever followed by gradual improve- 
ment are characteristic of spinal licemorrliage. There is much less 
pain than in meningeal licemorrliage, while the dissociation of 
cutaneous sensation is very characteristic. In acute softening 
there is less of the dissociation of sensation, but a more extensive 
paralysis. The latter may be mistaken for acute primary myelitis, 
which does often follow. Meningeal ha9morrhage is usually more 
painful, and there is less paralysis, more spasm, and a more com- 
plete recovery afterward. 

Prognosis. — This is often serious as regards life, and it is 
dubious as to recovery of power. Both much depend on the 



DISEASES OF THE SPIXAL CORD 24=1 

extent and seat of the haemorrhages. Dorsal hiTmorrhages are 
more favourable, cervical the least. 

Treatment. — Cold to the spine, such as through ice-bags, asso- 
ciated with absolute rest, together with small doses of cardiac de- 
pressants, as aconite, can be tried. Treatment must be prompt 
if any good is at all to be done. The after-treatment is entirely 
symptomatic, and later it is for the myelitis that may follow as a 
sequela (see M3'elitis). 



SYRINGOMYELIA 

Is an affection of the spinal cord, which, while not more rare 
than disseminated sclerosis, has only been in recent years brought 
to full light. The disease was first accurately described by 
Schultze in 1886 ; since that time there have been some hundred 
cases reported in the literature, and in the light of the pathological 
findings undoubtedly many obscure cases of cord disease reported 
in the past have been of this nature. 

There are two varieties of dilatation of the spinal cord : First, 
hydromyelia, which is a dilatation of the central canal, this being 
lined by the normal columnar epithelium. This condition may 
give rise to the symptoms of syringomyelia proper, similar to the 
second type, where the cavity occurs within the gray matter of the 
cord, but, as a rule, is separated from the central canal. A cavity 
or cavities in this instance are the result of softening areas in glio- 
matosis in the gray cord. The latter condition is probably hered- 
itar}', being an unnatural excess in development and continuance 
of the formation of this embryological tissue. The cavities may 
be single, multiple, or consist of numerous dilatations connected 
by irregular and deviating sinusesj so that one opening may be 
in this manner connected with another at a distance longitudinally 
from the first one. One-half the cord may be involved alone, or 
be at least more diseased than the other half. The cervico-dorsal 
cord is the most frequent site of the disease : although the medulla 
and pons, or lumbar and sacral cord, may be involved. That the 
disease has occurred following the infectious fevers does not 
particularly show them to be causative of the malady; so 
that the hereditary feature is the principal point in aetiology, as 
nlroaflv indicated. 



248 



TREATISE OX XEEYOUS DISEASES 



^. 



Symptomatology. — Four distinctive types of symptoms exist in 
certain groups of cases of syringom3'elia;, viz. : 

1. The ordinary type described above. 

2. Motor typC;, resembling amyotrophic lateral sclerosis. 

3. Sensory type, in which disturbances of sensation, particu- 
larly loss of thermic sense due to disease in Gower's tract, are 
prominent features. It may be hemiplegic in distribution, or in 
irregular areas. 

4. Those cases with pronounced trophic changes, painful whit- 
lows, etc., as described by Schlesinger in 1895. 

The disease may re- 
semble a number of 
chronic cord diseases 
in its plinical aspect, de- 
pending upon the im- 
pingement of the de- 
structive lesion in vari- 
ous anatomico-physio- 
logical centres and 
tracts. Thus syringo- 
myelia may resemble 
tabes of an irregular 
type when the posterior 
columns of the white 
matter are invaded, or it 
may present particularly 
the picture of progressive 
muscular atrophy of spinal origin if the dilatation occurs towards 
the anterior horns of the gray matter. In rare cases the disease 
may simulate spastic paralysis due to irritation of the lateral col- 
umns of the spinal cord : or in the rarest cases it may simulate in- 
sular sclerosis. So that given a case of chronic spinal cord disease 
of atypical or irregular manifestations, syringomyelia must be 
thought of. The particular symptom of diagnostic import is the 
dissociation of sensory phenomena — for example, there is usually 
loss of pain and temperature sense in irregular areas (analgesia 
and thermo-angesthesia), with preservation of the sense of touch 
and muscle sense. If the cavity is on one side of the cord alone, 
and is of considerable size, we may have symptoms of Brown- 
Sequard paralysis, to be told from the usual type of '^crossed 




Fig. 59.— Atrophy of Intrinsic Muscles of 
THE Hand and Thermo-An^sthesia in 
A Case op Syringomyelia. (Philadelphia 
Hospital.) 



DISEASES OF THE SPIXAL COED 249 

paralysis '' of this sort by the absence of pain and temperature sense 
rather than the touch and muscular sense, as indicated; or as in 
spinal tumour or unilateral sclerosis, anaesthesia would be the sen- 
sory manifestation more particularly, or all forms of sensation 
would be absent. In cases where the cervical cord is affected high 
up the ascending branch of the fifth nerve may be affected, produ- 
cing anaesthesia of the face. From involvement of the cervical sym- 
pathetic, the pupil on the affected side may be contracted, and there 
may be an absence of sweating on the same side of the face. Lordo- 
sis or scoliosis may occur in cases where the spinal centres govern- 
ing the muscles of the spinal column are destroyed, this permitting 
muscular atrophies and consequent spinal curvature. In some cases 
motor cells of the spinal column are destroyed, permitting mus- 
cular atrophies and consequent spinal curvature. In many cases 
there is absence of the deep reflexes in the upper extremities ; or if 
the disease descends low enough the knee-jerk may be absent — 
all depending upon destruction of the posterior roots of the 
spinal cord. The atrophy may extend to the lower extremities, 
and there may be reaction of degeneration found in the affected 
muscles. The course of the disease is slow, and may at any time 
come to a standstill. There may be remissions in the clinical 
course, no doubt due to extension of the process being abated. 
The patient may die from involvement of the cardio-respiratory 
centres in the medulla. 

Treatment of this affection is of little value, although gen- 
eral hygienic measures to control the circulation by means of 
proper woollen clothing and the protection of the individual 
against inclement weather is to be instituted. Such patients 
should live an inactive life in the open air and sunshine. Contin- 
uous doses of iodide of potash may do good in the minority of 
cases through the alterative and sorbefacient effects of the drug. 
Ee-education by exercises will prove of value where ataxia exists. 
Massage and static electricity may aid nutrition, better the cir- 
culation, and assist in staying the muscular wasting and sensory 
changes. 



250 TEEATISE ON NERVOUS DISEASES 

MUSCULAR DYSTROPHIES 

These are classed under diseases of the nervous system, 
although no constant pathological finding has been found in the 
nervous S3'steni. Palsy is, however, a constant neurological symp- 
tom of all of them. There are three forms of muscular dystrophies, 
so called : 

1. Pseudo-hypertrophic paral3'sis (Duchenne). 

2. Idiopathic muscular atrophy. 

3. Neuritic form of muscular atrophy (Charcot-Marie-Tooth). 

(1) Pseudo-hypertrophic Paralysis. — The first, a disease begin- 
ning in early childhood, is a family type of disorder, although not 
known to be directly hereditary. The progenitors of the patient 
will be found to be alcoholics, subjects of syphilis, or some other 
form of degenerative disease. This has been satisfactorily proved 
to us in investigations made by Wharton Sinkler and the writer 
in a statistical study made in the Infirmary of Nervous Diseases 
of Philadelphia in 1899.^ " 

Males are more frequently affected, and several in the family 
may be picked out, others escaping. The age limit of five to ten 
is the most usual time of onset. The patient first complains of 
feebleness in progression, and it will be noted that there is slight 
toe-drop, that the calves of the legs are enlarged, which greatly 
increase, causing a sense of firmness to palpation. Other points 
of pseudo-hypertrophy may exist in the pectoral muscles, the del- 
toids, and about the shoulder-girdle. With the enlargement comes 
on an increasing weakness of the muscles involved (Fig. 60). An 
early and characteristic feature is difficulty in arising from a 
supine position. The patient contorts the trunk in the endeavour 
to aid the specially weakened extremities, beginning by pushing the 
body up with the hands upon the thighs, then forcing the trunk to 
the vertical, thus extending the trunk upon the thighs, then draw- 
ing the lower extremities into the erect posture. The characteristic 
attitude is the hand-over-hand method in pushing up the trunk 
with the arms, in bringing the body to the erect position. This 
characteristic sign of the paresis may last for many months. 
There is no true ataxia, however. The patient is seen to have 
difficulty in mounting steps, and will frequently trip over slight 

^ Journal of American Medical Association, November, 1890, Family Dis- 
eases* 



DISEASES OF THE SPiXAL CORD 



251 



elevations on the surface. Finally the patient cannot rise from 
the sitting position, and it will then he found that the muscles, 
which were apparently enlarged, have atrophied down to the nor- 
mal size perhaps, or beyond this, and are board-like to the sense 
of touch. Other muscles may pass directly into atrophy without 
any pre-existent enlargement. 

Reflexes. — The deep reHexes will be found lessened or absent 




Fig. 60.— PsErDOHTPERTROPHic Paralysis sho^win-g Atrophy of Shoulder. 
Girdle. a>'d Thighs; also Manner of Risin'g in the Order 1. 2. 3. 
(^Medico-Chinrrgical Hospital ) 

and the superficial reflexes diminished. The end picture in this 
malady is of extreme muscular atrophy and al)solute helplessness. 
Coldness of the extremities, cyanosis, enfeebled heart action, and 
general lessening of the functionation of the s})ecial senses witli 
mental deterioration, occurs later in the affection, with dribbling 
of saliva from mouth, difficultv in swallowino-. etc. The averaofe 



262 TREATISE ON NEEVOUS DISEASES 

duration of the disease is from one to twenty years^, yet depending 
much upon the preserved nutrition and vegetative function of the 
patient; also upon his immunity or the absence of any of the 
complicating infectious diseases^ which are particularly fatal in 
them. If not carried off by intercurrent disease, the' patient may 
die of heart failure, from involvement of that organ. 

Pathology. — This consists of excessive deposit of fat cells 
within the sarcolemma, and fatty change and swelling, loss ,of 
striation of the muscle cells. Overgrowth of connective tissue 
also takes place between the muscle cells. As the disease progresses 
the disappearance of the fat cells takes place, connective-tissue 
growth predominates, and the muscle substance is degenerated, 
leaving debiis and connective tissue instead. 

Diagnosis. — This should not be confounded with any other 
disease. In neuritis there is pain and tenderness of nerve trunks. 

Prognosis. — An incurable malady. There may be prolonged 
remissions. 

Treatment. — Much can be done to stay the progress of the dys- 
trophy. This consists in persistent, scientific use of massage to 
favour better circulation, as well as of the elimination of the 
products of catabolism, and to prevent retrograde change in the 
muscle cells. Nutritious diet, consisting of eggs, red meats, or 
any other nutritious proteids, is indicated. Vegetables containing 
iron are valuable in this disease, in which metabolism is so per- 
verted. In spinach iron can be introduced into the blood with 
least gastric disturbance.' The overdistention of the stomach with" 
carbohydrates is most certain to do harm. Predigested foods, as 
beef, is only called for when the stomach absolutely refuses to digest 
the more ordinary foodstuffs suggested. Electricity does not aid 
us much, although the static breeze may be of value in stimulating 
the circulation at the periphery, and to the carrying off of the waste 
products. The hypophosphites, phosphorus, and strychnine as a 
nerve tonic are all of value in this chronic disorder. Such patients 
should be carefully protected from cold and dampness, and given 
plenty of fresh air and sunlight, in a stimulating climate, at low 
altitudes. Sea air is particularly bracing. 

(2) Idiopathic muscular atrophy is of two types: (a) the 
fascio-scapulo-humeral type (Landouzy-Dejerine), and {l) the 
juvenile form of Erb. 

{a) In the former the atrophy begins in the orbicularis oris and 




Fig. 61.— Progressive Muscular Atrophy of Spinal Origin (Anterior Pol- 
iomyelitis Chronica) showing Wrist-Drop, Atrophy of Hand Muscles, 
AND OF Shoulder Girdle, and the Pectoral Muscles. (Medico-Chirur- 
gical Hospital.) 



254 TREATISE ON NERVOUS DISEASES 

the face, producing the hollow-cheek appearance, the so-called 
" tapir mouth," and accompanied by fibrillary twitching of the 
muscles involved. This atrophy progresses in the trapezius and 
deltoid muscles, upper part of the arms, until within six months 
or a year there is a very marked physical change in the appearance 
of the upper portion of the body. The patient is unable to adcluct 
or abduct the extremities, and particularly to raise the arms on 
a level with shoulder. Finally, the atrophy extends to the lower 
part of the arm and interosseous muscles, the lower extremities 
becoming involved last, if at all, in proportion with the duration of 
the case. 

(h) The juvenile form begins in the interosseous muscles of 
the upper extremities, the thenar and hypothenar eminences, ex- 
tending to the upper arm, finally to the lower extremities — 
thighs and legs — the patient's progression being with feebleness 
and evident toe-drop. This occurs most frequently between the 
ages of twelve and sixteen. It is very slow in progression, the pa- 
tient living for many years. The vaso-motor weakness is shown by 
coldness and clamminess of the extremities, the indurated condition 
of the skin, brittle nails, etc. The deep reflexes are abolished 
early, but there is no reaction of degeneration, except in rare in- 
stances, very late in the course of the disease and where particu- 
larly large bundles of fibres are affected in the muscle atrophy. 

The sub-type known as progressive muscular atrophy of spinal 
origin has a similar symptomatology, but begins in early adult life. 
This is the so-called poliomyelitis chronica. At times there is 
pain, the marked feature being fibrillary, contractions, also that 
it occurs later in life than the muscular dystrophies proper, and 
that in the pathology of the disease, in addition to atrophy of the 
muscle cells and overgrowth of connective tissue, there is a degen- 
eration of the multipolar cells in the anterior cornu of the gray 
matter of the cord. 

(3) The so-called neuritic type is that which begins in the 
perineal muscles, producing peculiar guttering in the perineal 
region of the legs, with infrequently a toe-drop, and the process 
gradually extending up the thighs, and finally affecting the gen- 
eral musculature. 

Pathology.— The pathology of this affection is not known fur- 
ther than the involvement of the muscles in atrophy and over- 
growth of connective tissue. 



DISEASES OF THE SPINAL CORD 255 

TrcaliHcnf. — In all tlie^^e different forms of muscular atrophy it 
is largely symptomatic. Mechanical stimulation of the muscles 
directly by means of massage^ Swedish mo\xunents^ or galvanism 
are to be assiduously applied. Static electricity is a valuable 
agent to promote nutrition and bettered circulation in the tissues. 
The orthopaedist should be consulted in many of these cases in 
order to prevent deformities as well as to strengthen joints en- 
feebled by the muscular disease, thus making life more useful 
in these patients, who might otherwise be prematurely crippled." 
The hypophosphites and cod-liver oil, plus a nutritious diet, con- 
sisting largely of proteids, with the use of eliminants, as copious 
draughts of water, the various mineral waters being particularly 
adaptable, are all agents of vital importance. Much can be done 
for these patients in the way of alleviation by persistent endeavour, 
even though cure is not established. Strychnine is of value in 
fairly large dosage — gr. ^-^ to -^-^ t. i. d. 



ANTERIOR POLIOMYELITIS ACUTA OR 
INFANTILE PARALYSIS 

This is a disease of sudden onset, more 'frequently seen in child- 
hood, and is probably of microbic nature. The disease is fulminat- 
ing, and is, as a rule, ushered in by a chill, followed by hyperpy- 
rexia (104° F. or more),. accompanied by nausea and vomiting and 
general restlessness. With these there may be hypersesthesia and 
sensitiveness of one or more extremities. The fever lasts from 
several to fortj-eight hours, as the case may be, when it will abate 
and the patient be left in a generally weakened condition, with 
palsy of one lower extremity, as a rule. Rapid wasting will super- 
vene in the paralyzed part, and at the end of ten days or two 
weeks reaction of degeneration will be found in the paralyzed mus- 
cles. One lower extremity is generally involved, and the anterior 
tibial group more than other muscles, the next in frequency being 
the calf, the extensor femori, and the adductor muscles. Rarely 
an upper extremity is alone aifected. There will be found an 
absence of the deep reflexes; as a rule the knee-jerk is wanting 
where the lower extremity is involved. The limb becomes cold, 
clamni}^, cyanosed, and wasted. If the member is not totally para- 
h^zed, the patient will be able to limp about, and contractures, de- 
formities of the limb, such as acquired clubfoot, occur later. The 



256 TREATISE OK NERVOUS DISEASES 

disease very seldom extends to other parts of the cord after the 
original attack; the patient generally recovers full and usual 
health. The paralyzed extremity does not grow in length as do 
the others^, and in consequence of the shortened limb there may be 
a spinal curvature as a remote consequence. The sphincters are 
never involved in the acute attack of infantile paralysis. Decubitus 
seldom results. The symptom of " palsy '' is at first rather rapid 
in its partial recovery, then promptly progressive. In some cases 
the deep reflexes are retained or increased. It may occur in epi- 
demic form in spring and summer. 

Patliologij. — This consists of acute inflammation of the multi- 
polar cells in the anterior horns of the gray matter of the cord, 
usually in the dorso-lumbar region. Following the inflammation 
there is found a degeneration of the multipolar cells, overgrowth 
of connective tissue, and molecular debris ; also degeneration of the 
nerves coming from this particular segm^ent of the cord, with 
atrophy and fatty degeneration of the muscles supplied by them. 

Diagnosis. — In neuritis there is tenderness of the nerve-trunks, 
and as a rule it is less sudden in onset, with less severe palsy, though 
a more general and constantly progressive or regressive paralysis. 

Some cases of hip- joint disease may simulate* infantile palsy 
only in inability to move the extremity. The hip-joint would be 
partially ankylosed in coxalgia. The pseudo-palsy of rickets is 
always associated with that disease and there is little wasting and 
no history of an " attack.'' The knee-jerk is capricious. 

Pseudo-muscular atrophy or other local forms of dystrophies 
need but to be mentioned ; as well as the cerebral palsies of child- 
hood, which latter are associated with spasticity; while the former 
are gradual in onset and widespread. 

Prognosis. — This depends entirely upon the degree and extent 
of involvement of the gray matter of the cord. An attack very 
seldom kills. If a few muscle-bands are affected, it is possible that 
almost complete recovery may occur with time and proper treat- 
ment. Where one member is markedly paralyzed usually consider- 
able power will be restored within a few months' time, when fur- 
ther recovery of the individual muscles will seldom take place. 

Treatment. — This consists in the management of the attack, 
which would be as of an ordinary acute infection, treating the 
hyperpyrexia, giving a calomel purge, and protecting the affected 
limb by carefully bandaging in cotton. After the acute stage has 



DISEASES OF THE SPINAL CORD 257 

subsided, the general nutrition of the patient should be looked 
after. The use of the hypophosphites and a careful dietar}' are 
important, the remainder of the treatment being entirely local. 
This consists in massage and galvanism to the paral3'zed muscles, 
continued for months or years, depending upon the severity of the 
case. ^ If the child is able and there is no tendency to deformity, 
it can walk about; or if there be a tendency to deformity, the 
orthopaedist should be consulted with the hope of '* bracing " the 
weakened limb to prevent deformity that may occur in such cases. 
A high shoe may be necessary for the paralyzed limb where there 
is marked slowness of growth in it. The use of strychnine is of 
value, and should be given in doses according to the age, over 
prolonged periods of time. In inclement weather these patients 
should always be well clothed. They should be especially well 
protected against cold of winter and sequent frost-bite. 

In cases where there is very little power remaining in an ex- 
tremity, a method of assisting the exercise of the muscles is by 
daily immersing the child in a warm bath and permitting him to 
" float '" the affected limb about in the water. The weight of the 
water displaced by the member will be just that amount of relief 
of dead weight in attempted exercising. I have seen great good 
from this method of treatment in one case. 

GLOSSO-LABIO-PHARYNGEAL PALSY, OR BULBAR 

PARALYSIS 

Bulbar paralysis applies to a number of systematized symp- 
toms, due to diseases or lack of functionation in the centres in 
the bulb or oblongata (fifth, seventh, ninth, tenth, eleventh, and 
twelfth cranial nerves), and is divided into several varieties: (1) 
acute, (2) chronic, (3) asthenic, and (4) pseudo. 

Symptoms. — These may accompany other diseases, such as 
amyotrophic lateral sclerosis, etc. 

(1) The symptoms of acute hulhar paralysis are a sudden 
onset, dribbling of saliva, with the motor difficulty (dysarthria) of 
speech, and atrophy of the tongue. This acute form may be 
ushered in by an apoplectiform attack. It is also known as polio- 
encepJialitis inferior. The symptoms are rapidly progressive, the 
patient losing the power to swallow. With the dysphagia there 
is loss of flesh. The patient is the subject of choking spells on 
attempting to swallow either solids or, in bad cases, liquids. In 
17 



258 TEEATISE OX XERVOUS DISEASES 

this affection the j^atient is perfectly conscious, hut at times it is a 
difficult matter to determine whether the mind is affected or not, 
owing to the motor difficulty of speech. The latter is of a drawling 
nature, the words heing prolonged, the consonants first being 
affected : finally the inability to pronounce words of more than one 
syllable with any degree of distinctness. The patient, however, 
is able to write perfectly well. With this added fact, bulbar paral- 
ysis is easily diagnosed from any form of aphasia. 

The course of the disease is very rapid, and within three or 
four months' time the patient is in a very serious condition. Death 
is frequently caused by an inspiration pneumonia, or a sudden 
attack of choking : or from respiratory or heart failure, due to the 
involvement of the vagi centres. 

(2) The chronic type of bulbar paralysis is much slower in 
its progress. The symptoms — stuttering, dysphagia, regurgitation 
of liquids from the nose on attempting to swallow — being more 
gradual in progress. The patient otherwise keeps in fairly good 
health, since the slowness of the process does not deprive him from 
getting ample nourishment until late in the course of the disease. 
The main difference between this and the acute form of the dis- 
ease lies in the rapid progress of the latter, accompanied by 
general wasting, and the slower progress of the former. 

The pathology of these forms is different in that in the acute 
types there is inflammation, a softening process, or minute haem- 
orrhages into the bulbo pons and cord, while the symptoms are 
apt to be consistently bilateral from the first: whereas in the 
chronic form, which is due to atrophy of the motor neurones, there 
is simply an aggression of the symptoms of one side out of propor- 
tion to the other, although both are involved. The duration of 
the chronic type is from eigliteen months to three years. The 
patient may suffer from irregular cardiac action and attacks of 
tachycardia. It is somewhat singular that heart failure does not 
occur more frequently at the very onset of the disease, because of 
the involvement of the vagus centre. 

The prognosis of both of the above forms is unpromising. 
Eesults of treatment may but ameliorate. 

The treatment is more palliative than anything else, but con- 
siderable can be done in chronic cases to alleviate suffering by 
a careful attention to the manner of food administration, the use 
of the stomach-tube beins: a valuable method of feeding the 



DISEASES OF THE SPINAL rORl) 250 

patient. This should be done at regular intervals during the 
course of the disease, even when the patient can swallow only a 
small amount, since in this there is liability to " inspiration " 
pneumonia. The use of strychnine in fairly large doses (3^0 to gV 
of a grain, t. i. d.) is of great value. The patient should live a very 
quiet life. Galvanism to the throat muscles is of value. Treat- 
ment of complications, such as pneumonia, is medical detail that 
need not be given here. 

(3) The asthenic form of bulbar paralysis occurs later in life 
than the organic forms, and is more frequent in women than in 
men, occurring about the age of forty. It is designated asthenic 
because no definite lesion has as yet been determined, there being 
asthenia of the throat muscles. 

The pathology is very like an auto-intoxication due to deficiency 
of metabolism, weakening the bulbar centres. The muscles sup- 
plied by the motor cranial nerves are involved; the centres are not 
able to generate or transmute nervous energy. Besides the symp- 
toms already rehearsed other characteristic features of this form 
of disease are the remissions which recur in it regularly from time 
to time. Thus a patient may be unable to speak save in a whisper 
or in very indistinct monosyllables for a week or ten days, bodily 
weakness being present at the same time, and within a fortnight 
the voice may have returned, the patient having become much 
brighter mentally, and physically stronger. 

Prognosis. — This is not good as to recovery, but the patient 
may live for many years in comparative comfort between the 
attacks, although harassed at frequent intervals by aggression 
of the symptoms. I have had the pleasure of observing a case of 
this sort with Dr. Wharton Sinkler at the Orthopaedic Hospital 
for some three or four years. 

(4) Pseudo-hulhar palsy is a type of progressive failure of 
the glosso-labio-pharyngeal muscles unassociated by atrophy of 
muscles or general weakness. 

The lesion is very likely cerebral, affecting the upper motor neu- 
rones of the motor cranial nerves, particularly the ninth and tenth. 

Treatment of pseudo and asthenic bulbar palsies does not differ 
from that of the chronic type. Good food, out-of-door life, arsenic, 
strychnine, the hypophosphites and glycerophosphates being of 
importance; also the use of gavage. 



260 TEEATISE OX XERVOUS DISEASES 

THE COMBINED SCLEROSES 

By the combined scleroses is meant those forms of degeneration 
in which both the lateral and the posterior columns are affected. 
Westphal first described the condition in 1867. There are several 
types : 

(1) Hereditary spinal ataxia (Friedreich's disease and hered- 
itary ataxic paraplegia). 

(2) Combined sclerosis in anaemic and toxic states (Putnam 
and Dana type). 

(3) Combined sclerosis complicating general paresis. 

(4) Accidental forms, as Gowers's ataxic paraplegia. 

The clinical pictures of the many reported cases of combined 
scleroses vary greatly. Such cases must be of chronic ascending 
myelitis or meningomyelitis followed by degeneration. Accord- 
ing to Marie and others, the vascular supply of the spinal cord 
is such as to favour sclerosis in the lateral and posterior columns, 
hence chronic leptomeningitis, many instances of which are due to 
syphilitic infection. The ataxic paraplegia described by Cowers, 
in which he believed the sclerosis lay in the lateral and posterior 
columns of the cord, is still observed as a clinical entity : but many 
similar cases can best be classed with tabes, with insular sclerosis, or 
with a form of limited chronic myelitis. TTe shall describe, there- 
fore, only the hereditary form of ataxia with paraplegia, which is 
congenital and a family disease closely related to Friedreich's 
ataxia ; also the type of combined sclerosis in which ataxia, some 
sensory and motor symptoms, are found associated with pernicious 
angemia. There is no particular clinical picture attached to the 
cases of combined scleroses described by Striimpell and others 
with autopsies ; hence the two above-indicated types at the present 
stage of our scientific knowledge, that are proper subjects for accu- 
rate description, clinically and pathologically, are (1) hereditary 
ataxia (see Friedreich's ataxia, p. 238) and (2) the combined scle- 
roses of ancemia, etc.. as described by Lichthein. Putnam, and Dana. 

(2) COMBINED SCLEROSIS OF THE TYPE OF 
PUTNAM-LICHTHEIN-DANA 

This affection occurs past middle life, and is usually associated 
with cachexia, a pernicious anaemia, or some toxic states, as in 
influenza, lead poisoning, malaria, or chronic diarrhoea. Fre- 



DISEASES OF THE SPIXAL CORD 



261 



qiiently there is a 
liistory of heredity. 
This disease was de- 
scribed as develop- 
ing in the course of 
anaemia by Lichthein 
in 1877; those pro- 
duced by other 
causes by Putnam, 
and in 1891 again 
by Dana. 

Symptoms. — 
The earliest symp- 
toms are persistent 
pargesthesia, accom- 
panied by slight 
weakness, most com- 
monly in the feet, 
and somewliat later 
followed by ataxia. 
Pain in the limbs 
and back may exist. 
At first there is 
some spasticity of 
the muscles, in- 
creased knee-jerks, 
and ankle clonus. 
Later in the disease 
the rigidity may dis- 
appear and reflexes 
be lost in the lower 
extremities. After 
some months the 
arms become affect- 
ed and symptoms 
develop similar to 
those in the legs. 
Occasionally the dis- 
ease begins in the 
upper extremities. 




Fig. 62. — Combined Sclerosis of the Type Put- 
nam -Lichthein -Dana FOLLOWED BY LeFT 
Hemiparesis. (Medico-Chirurgical Hospital.) 



262 TREATISE ON NERA^OUS DISEASES 

Lessening or absence of pain, tactile and thermic senses may 
occur, or there may be dissociated sensation, as in case of syringo- 
myelia. In the course of the disease dementia may develop. 

Pathology. — The posterior columns are first and mostly in- 
volved. In some cases of pernicious anaemia these were the only 
columns that were found to be sclerosed. In the majority of cases 
the lateral columns (crossed pyramidal tracts) are affected as 
well, and late in the course of the disease the anterior colunins 
may be attacked. Softening of the cord with the production of 
cavities may appear. The condition is essentially a primary degen- 
eration of the nerve-fibres. 

Diagnosis. — This is to be distinguished from tabes. It is rapid 
in onset and there is some motor weakness, but absence of ocular 
symptoms is characteristic, while the early increase of knee-jerks 
with the anaemia should be taken into consideration. From ataxic 
paraplegia or posterior lateral sclerosis it is also told by its rapid 
development, the greater degree of weakness, and the constitu- 
tional s3^mptoms. Those cases with dissociation of sensation are 
also distinguished from syringomyelia by the absence of severe 
pain and tenderness or of marked muscular wasting. 

Prognosis. — This is unfavourable. In the majority of cases 
the patient will not survive longer than six months to several years, 
although cases of great improvement have been reported. 

Treatment. — Hypernutrition, rest, massage, and Swedish 
movements. Measures tending strictly towards eradicating the 
diathetic or specific conditions underlying should be employed. 
The anaemia or any form of intoxication should be treated. The 
drugs of value in the disease are arsenic, quinine, iron, and other 
tonics, together with nutrients. 

Re-education of the ataxic extremities can be had where im- 
provement may happily occur if asthenia is not too great. 



INFLAMMATIONS OF THE SPINAL CORD-MYELITIS 

Myelitis, an inflammatory lesion of the spinal cord, is a dis- 
ease rather insidious in onset, sometimes very abrupt, and running 
a course of several degrees; the first, or mildest, which fre- 
quently recovers, leaving little damage to the organic constitu- 
ents of the cord ; the second, running a serious course, and after 
subsiding the individual is a paraplegic; while the third type 



DISEASES OF THE SPINAL COED 263 

is malignant, rapid destruction of the cord and death of the patient 
follows. 

Causes. — These are exposure to cold and dampness; injury, 
such as a trauma to the back; or it may be of a septic nature, due 
to metastasis from other seats of infection, including tubercular. 

Myelitis is much more frequently met with in the male, on 
account of the liability lo exposure in men. 

Pathology. — This condition consists of a low grade of in- 
flammation with infiltration of round cells within the gray and 
white matter, more particularly of the gray matter. Granular 
debris is the result, plus fatty degeneration- of the nerve-cells, and 
their replacement by connective-tissue elements. Where the proc- 
ess has been insidious and mild the neurones throughout the 
transverse section of the cord will be found but partially degen- 
erated. In malignant cases there is a complete destruction of the 
parenchyma of the cord (see Infantile Palsy). 

Depending upon the extent of lesion, we have transverse, as- 
cending, and descending myelitis. The lesion of poliomyelitis 
need' not be mentioned here. 

Symptoms. — There is a rather sudden onset, a slight rise in 
temperature, par^esthesia and feebleness of the lower extremities. 
This continues more or less rapidly until the patient within a few 
days becomes bedridden, incontinence of urine follows, and per- 
haps of the rectal sphincter. The upper extremities may be in- 
volved, depending upon the site of inflammation, but usually 
not, since the process is generally confined to the lumbar cord. 
In the beginning the reflexes are heightened, ankle clonus even 
may develop, and the patient have a spastic gait and become 
more or less ataxic, depending upon the degree of involvement of 
the posterior white columns. Usually the gray matter is more 
involved, and if the multipolar cells are affected distinct atrophy 
and wasting of the muscles will follow. In a rapidly progressive 
myelitis, paraesthesia and hyperaesthesia (irritative symptoms) 
will within a few days to a week be replaced by a hypgesthesia or 
anaesthesia, involving both lower extremities very likely in their 
extent, or the trunk may be thus affected as high up as the umbili- 
cus. At this stage bladder distress from incontinence and paresis 
of the detrusor muscle will permit of retention of urine as well, 
and resulting cj^stitis. At this time, too, bedsores may occur, par- 
ticularly liable over the buttocks and sacral region, due to the low- 



264 TREATISE 0^ NERVOUS DISEASES 

ered trophic condition and pressure upon these dependent parts. 
At this last stage the reflexes will be abolished. The patient is rest- 
less^ loses flesh, and becomes hectic, and may go into a septicaemia, 
which may cause death ; or after a number of weeks the inflamma- 
tion" may subside and the paresis partly recover, permitting the 
patient to get abont on crutches within a few months to a year. 
In other cases the destruction of the cord may be so absolute 
that even partial recovery of function seldom occurs, although 
held in abeyance, and the patient may go on living a vegetative 
life for some months or years. This is especially apt to result 
in those cases of traumatic origin, such as in " broken back " of 
the coal miner. 

In some few cases I have seen almost entire recovery after a 
most severe attack, and in these cases it is very likely that the 
meninges have been particularly involved, and while the function 
of the cord for the time is greatly interfered with, the absolute 
destruction of the neurones has not occurred. The extremities in- 
volved in myelitis become cold, clammy, cyanosed, etc. On begin- 
ning recovery of a case the patient moves about with a spastic 
gait, which he will retain in some measure, although he may pretty 
completely recover from the palsy. 

Diagnosis. — This is to be made from neuritis, where pain and 
tenderness along nerve-trunks would differentiate; from subacute 
rheumatism of the limbs, which would be distinguished by the 
nature and distribution (to the joints) of the pain with other symp- 
toms of the rheumatic disorder; and finally from syphilis of the 
spinal cord, where the course of the disease is much slower, and 
spasticity is out of proportion to palsy. In syphilis too seldom are 
the signs equally bilateral ; paresis is less marked and muscle tone 
not increasing in proportion to the heightened reflexes existing, as 
indicated. 

Prognosis. — This is a very difficult matter to determine. It 
should be held in abeyance until the first few weeks of the dis- 
ease have passed, and will depend in some measure upon the phys- 
ical stamina of the patient, although distinctly plethoric persons 
are apt to suffer the greatest. Infectious cases particularly will 
often recover more completely than the so-called idiopathic class. 
The tubercular cases are the most promising for restoration of 
the function of the cord. Here, again, the inflammation is liable 
to be localized in the membranes. 



DISEASES OF THE SPINAL COED 265 

Treatment.^This consists in absolute rest in bed, preferably a 
water-bed; the use of mild antipyretics, if the case is fulminating 
in type, and there is much constitutional involvement. Protection 
should be had to the extremities by means of " hoops " to sustain 
the bed-clothing, and the dependent part should be amply guarded 
against prolonged pressure by frequent changes of the position of 
the patient. The use of analgesics may be necessary (phenacetine, 
5 grains) where there is considerable distress. The bladder should 
be guarded, especially for retention of urine, by a careful use of 
the catheter, both to prevent injury of the mucous membrane and 
from the aseptic point of view. If marked cystitis develops it may 
be necessary to flush the bladder with some antiseptic solution, as 
boracic acid or a minimum solution of potassium permanganate 
(1 grain to a quart of water). The decubitus developing should 
be antiseptically cleansed, and a soap plaster placed around the 
adjacent tissues to prevent pressure on the sore, the latter being 
antiseptically treated. The so-called " ring,'' when used, I have not 
seen of practical value, since it disturbs the patient, and will slip 
and only do more damage in the already inflamed area. Among 
drugs, the solution of potassium iodide, directed to be taken in 
5- to 10-grain doses, t. i. d., is of great value from its sorbefacient 
effect upon the exudate about and in the cord substance. This 
should not be pushed to a high dosage, as in cases of specific dis- 
ease, which shall be mentioned in the next chapter. Prolonged 
rest is essential for the hastening of good results. The necessity 
for care of the skin in any case is to be insisted upon by the proper 
bathing and stimulation with alcohol, etc. Thorough massage is a 
valuable aid in restoration of tone of the muscles in convalescing 
cases, and should be continued for months. When the patient gets 
about he should be cautioned to use crutches or a cane and to 
avoid activity, lest he increase the inflammatory process. 

The treatment for myelitis following Pott's disease differs in 
one particular — i. e., in the use of extension and counter-extension 
to the patient by means of the jury-mast, which is weighted from 
the head of the bed, the counter-extension being made by elevation 
of the head of the bed. This extension may be increased to from 
10 to 30 pounds, and s?iould be practically continuously applied to 
the patient until the inflammation of the vertebrae subsides and 
the palsy has partially recovered. This class of cases comes under 
the neurologist's care when the paraplegia is marked, and may 



266 TREATISE OX NERVOUS DISEASES 

reach the orthopaedist when the vertebral symptoms predominate. 
Another method of extension is by suspension of the patient while 
sitting in a chair by means of an inverted " L "-shaped rod at- 
tached to the back of the chair, to the short end of which a pulley, 
scales, and the head-extension apparatus is attached. This can be 
nicely adjusted to the weight desired for the extension. I have 
seen patients with complete motor and sensory palsy of three 
months' duration recover entirely from palsy, by combination of 
the bed-and-chair extension described, within seven months of per- 
sistent treatment. The tendency in these cases to relapse is to 
be noted, and a brace should always be worn afterward to support 
the spinal column. Cases of Pott's disease with suppuration are 
least apt to develop paralysis, very likely because extension is out- 
ward rather than inward" in pus cases; also due to the apparent 
immunity of nervous tissue to sepsis. 



CHAPTEB XV 

Knltiple sclerosia^ c: .:.s:la.: sclerosis, or disseminated sderosis, 
or sclerose en plaques^ : ± don characterized by focal 

areas of sderoisis ^cat-.- : . -^-rt- brain and cord; occa- 

sionally the sderoHLg i^ . : /_ or to the cord- 

^tioloffff. — ^M" _ T : T suit of traimia, as 

of the spine, to ti^- z:jiu.-i. ^ :i c^^i-i-^^c i-:. oold and wet when 
Tarions metaboHteg and toxiDs are developed in the blood as 
sonrces of irritation. Overwork may in the same way act as an 
exciting canse, as will emotional states, which may also mnch per- 
vert all bodily secretions and excretions. Infections diseases or 
the metallic poisons, snch as of lead or mercnry, may also act as 



Symptoms. — ^The symptoms will vary in aeeorda:i - — 'rii Tiir 
distribution of the sclerosis as well as its extent. > :/. - ir are 
certain signs and symptoms of sufficient importancr - - ::. r- 
acteiistic. These consist of weakness of one or morr -" " ?. 

snch as of the legs. The limbs become spastic, the ~ r-= 

being increased. A coar^ tremor develops in th^ z - ^ 

and this is of the intention type — L e.„ it is awfc> : - _ z^ ^ . :- 
ated by volition or a volnntary act- These irrer t 

involve the arms, legs, and finally the head. T: t :: - ^ 

subsides when the parts are at rest, and absol":r. - - : - f 
patient sleeps. Occasionally the tremor is so coarse :':.:,: z- 

cnlt to differentiate it from ataxic movements. XT-i^ii_:i^ i> a 
common symptom. This may be persistent, and is nsnally lateral 
nystagmus. It may, however, only be bron^t ont by having the 
patient strain the eye nrascles, as in looking far to one side in 
attempting to produce conjugate deviation. Ophthalmoplegia 
may finally oct?ur. Optic atrophy is frequently found, but the 
Argyll-Bobertson pupil seldom occurs. The lower cranial nerves, 
such as the fifth, seventh, and twelfth, may be also involved. 
Speech is apt to be affected; when it is slow and sing-song with 

297 



268 TEEATISE ON NERVOUS DISEASES 

elision of letters and words. The patient articulates as in scanning 
poetry^ the so-called staccato utterance or scanning speech. Some- 
times at3^pical forms of dysarthria, resembling the speech in bulbar 
palsy, or Friedreich's ataxia, or even paretic dementia, may be 
seen. At times patients affected with insular sclerosis may be sub- 
ject to attacks of vertigo, apoplectiform or epileptiform seizures. 
In unusual cases anaesthesia may be existent, when it occurs in 
the form of small irregular patches, although if a sensory tract is 
involved and destroyed high up hemianaesthesiamay result. Of 
course various forms of parsesthesia may be found, since irritation 
of sensory tracts without destruction of them is the more fre- 
quent condition present in the brain or cord in this disease. 

Diagnosis. — Most of the cardinal symptoms just enumerated 
will at once serve to differentiate this malady from any form of 
system disease, which latter would only be simulated where there 
is a large plaque involving a special tract, as the sensory, for ex- 
ample, as mentioned above. The symptoms may remain entirely 
cerebral or spinal. Remissions are frequent. 

Intention tremor, scanning speech, and nystagmus are rare in 
cerebrospinal syphilis; while in syphilis, too, there may be irido- 
plegia in one or both eyes, or the pupils may be irregular in con- 
tour from previous synechise, which latter would never occur in 
insular sclerosis (Sachs). The tremor of paralysis agitans is more 
marked when the part is at rest, and it is inhibited by volition or 
voluntary movements — a dynamic or continuous tremor. Parkin- 
son's disease is also one of old age, and true scanning speech or 
nystagmus are neither present in it. Paraplegic forms of infantile 
cerebral palsies are told by their appearance in very early life, 
occurrence of convulsions, associated with a more pronounced fail- 
ure of mental development. The diplegic type is more difficult to 
distinguish, since scannmg speech, nystagmus, and ataxic move- 
ments may be present. The syndrome of all three of these last- 
mentioned symptoms is, however, seldom found in cerebral palsy ; 
also paralysis and contractures are apt to be marked in cerebral 
palsy. In the hereditary ataxia of Friedreich, optic atrophy, less- 
ened or absent reflexes and ataxia of lower limbs are points in 
diagnosis. From the cerebellar type of hereditary ataxia it is more 
difficult to distinguish. Romberg's sign, which is present in cere- 
bellar ataxia, is, however, very rare in multiple sclerosis. 

Prognosis. — Insular sclerosis is slow in progress, but is incur- 



DIFFUSE DISEASES OF BRAIN AND CORD 2G9 



r\ 



able. Remissions nui}^ occur spontcineously or may be due to treat- 
ment in those patients with good physiques. 

Treatment. — Alterative remedies, such as arsenic or Donovan's 
solution, or even the iodides, may be of much service. Nitrate 
of silver has been commended, but I have never seen benefit from 
its use. Re-education by 
teaching the patient to co- 
ordinate is of value in the 
symptomatic management 
of the case. Massage is im- 
portant. General nutrition 
of the patient (such as 
through the administra- 
tion of syr. ferri iodidi, gtt. 
XV, t. i. d., or cod-liver oil 
gss. after meals) is the most 
important part of treatment. 



PARALYSIS AGITANS 
(SHAKING PALSY) 

Paralysis agitans is a 
disease occurring more fre- 
quently about the fifth dec- 
ade of life, and in which 
tremor and palsy are fea- 
tures. The name Parkin- 
son s disease is also applied. 

Causes. — Heredity, 
overwork, or trauma to 
spine. 

Symptoms. — The cardi- 
nal features are paresis, ac- 
companied by fine constant 
tremor, beginning as a rule 
in the hands, face, and 
lips, gradually spreading until the entire musculature is involved. 
The tremor is a continuous one in the majority of cases when the 
disease has become well established, although there is the unusually 
rare case that does not manifest tremor except periodically. The 




Fig. 63. — Expression, "Pill-rolling'' 
Hands, and Attitude in Paralysis Agi- 
tans (Adult Male ; but little Trem- 
or). (Philadelphia Hospital.) 



270 TREATISE ON NERVOUS DISEASES 

tremor is never what we designate an intention tremor — i. e., one 
brought out by voluntary movement of the parts; in this we have 
a diagnostic symptom, as between it and insular sclerosis, in which 
there is generally marked intention tremor. Other signs of paral- 
ysis agitans are a masked expression, the so-called " wooden face/^ 
due to rigidity and immobility of the muscles of expression ; and 
increased reflexes. With these there is slowness of cerebration, 
and still more of articulation due to mechanical interference with 
speech from lingual and phar3^ngeal involvement in the muscular 
rigidity and paresis. Later, as the disease slowly advances, drib- 
bling of saliva, very marked stooping of the body with rigidity of 
the neck, an assumption of the pill-rolling position of the hands 
and fingers are characteristic, and finally the festinating gait, or 
running gait as it is sometimes called. This gait is really an exag- 
geration of that of old age, and in which the patient is said to 
be running after his centre of gravity (not an inapt term). If 
the subject feels himself falling forward, the term propulsion is 
implied; if he has the sense of falling backward, we designate it 
retropulsion. The circulation is generally feeble in these patients, 
cardiac palpitation is not uncommon upon slight exertion, there 
is usually marked arteriosclerosis, and frequently iridoplegia in 
myosis. The tremor in its incipiency is also more marked when 
the patient is relaxed, though it is exaggerated with the relaxation 
following extraordinary exertion for him; and finally tremor may 
become so large and persistent that sleep is prevented from the 
mere mechanical effects upon the body, but when the patient does 
sleep the tremor disappears for the time being. Save for parses- 
thesia no sensory symptoms are found, excepting in rare cases, 
where there are rheumatic or articular changes of a trophic nature 
in the joints, when fleeting arthritic pains may occur. The patient 
is eventually compelled to give up the use of the hands, as in 
writing first, then of larger movements; although it is singular, 
the ability to write is preserved to extreme advance of the disease 
in some cases. Local flushing of the face and neck and body 
with evanescent sweating of the parts is always a notable symp- 
tom in this disease, due to vaso-motor irritability. The sphincter 
muscles are almost never incontinent. 

The duration of paralysis agitans is indefinite. As the disease 
is incurable in itself and occurs at the degenerative period of life, 
the demise of the patient will depend upon the complication of 



DIFFUSE DISEASES OF BKAIX AXD CORD 271 

other maladies, or upon the degree of degenerative tendency in 
the individual. The latter should be sought for in some measure 
by noting the heredity of the family. 

Pathology. — While no lesion has been found in the majority 
of cases coming to necropsy, in a fair proportion of them changes 
in the cord have been noted, largely consisting of congestion and 
dilatation of blood-vessels of the gray matter, atrophy and pig- 
mentation of nerve cells, and increase of the interstitial tissue. 
Dana considers, however, that the central motor neurone is most 
at fault. 

Prognosis. — As inferred from the above, recovery never occurs; 
but taken early, the malady can be controlled verv materially in 
25 per cent of the cases. Remissions and exacerbations are nota- 
ble. I have in mind a patient, who will be referred to under treat- 
ment, in whom there has been very marked amelioration of the 
symptoms, especially in the restoration of general tone to the sys- 
tem, although the tremor has never been greatly improved. An- 
other advanced case at the Philadelphia Hospital under my care 
has been greatly improved as to the tremor itself by therapeutic 
measures. TMiere it is clearly shown that there is no family tend- 
ency to the disease we can hope for better results than in cases 
with neurotic taint in a preceding generation. Just when the 
stage of paresis will develop cannot be accurately foretold, although 
generally speaking, the greater extent and range of tremor the 
earlier will palsy result. 

Treatment. — The essentials in treating paralysis agitans are 
rest and hypernutrition. In an incipient case, therefore, ideal 
treatment lies in change of scene, the leading of a quiet life, with 
abundance of fresh air and stmlight. Light gymnastics and pas- 
sive movements are of value in preventing rigidity of the limbs. 

Tonics, as quinine, arsenic, and mineral acids, are helpful. 
Warm baths daily and the constant galvanic current are of value. 
Hyoscine hydrobromate, gr. ^--J-g- t. i. d.. will frequently relieve the 
s}Tiiptom tremor, or a combination of tincture of conium and tinc- 
ture of hyoscyamus. ecjual parts, given in 5- to 10-drop doses, is 
of service. Gowers recommends cannabis indica and arsenic. I 
have seen the Brown- Secjuard ^ injections do good. Elimination 
through skin, kidneys, and intestinal tract must be regulated. 

* Testicles of healthy bulls are ligated and excised immediately after kill- 
ing the animal. Under antiseptic precautions the tunics are completely 



272 TREATISE ON ISTERA'DUS DISEASES 

SYPHILIS OF THE NERVOUS SYSTEM 

General Considerations and Distinctions 

Scientifically speaking, " syphilis of the nervous system " 
applies to the tertiary lesion located in the membranes of the brain 
or cord, or both; although parasyphilitic disease or the toxin stage 
(or qnarternary stage of some authors) is also a sequela of syph- 
ilis. In the latter, however (as in tabes and paresis), there are no 
characteristic lesions of syphilis. In it, too, the specific poison 
may expend itself upon the progeny, affect the general health, 
lessening resistance, and may create morbid tendencies or even 
sclerosis, as inferred above, in descendants of parasyphilitics. 

The acquired syphilitic diseases of this parasyphilitic stage 
may therefore be paresis, ataxia, neurasthenia, hysteria, epilepsy, 
and mental diseases. The congenital syphilitic diseases of this 
same stage may be arrest of development (as in Little's disease), 
hydrocephalus, paresis, juvenile tabes, the hereditary form of cere- 
bral palsies in children, etc. We have described all these various 
parasyphilitic diseases in other chapters. 

NERVOUS SYPHILIS 

General Considerations. — In the so-st3ded specific form of syph- 
ilitic disease of the central nervous system there may be the hered- 
itary or acquired forms. In the former, symptoms are present 
at birth or may appear early in childhood. Very rarely this 
form may even appear late in life, affecting all parts of the nervous 
S3^stem singly or collectively. The acquired and usual form may 
appear at various times after the primary lesion. Usually symp- 
toms present between eighteen months and six years. Some acute 
fulminating cases may even occur during the secondary period. 
Others may, exceptionally, occur even after thirty years of the 
luetic infection. 

Pathology. — There are various forms of tertiary lesion found. 

(1) Disease of Blood-Vessels. — Endarteritis ohliterans is fre- 
quently found in which there is proliferation of endothelial and 

removed down to and including the albuginea. The gland is then macerated 
in pure glycerin and allowed to dissolve for forty-eight hours. The whole is 
then filtered and a small extra amount of the liquid part of the residue is 
added to make a supersaturated solution. The mixture is then sealed in anti- 
septic phials. By this method one testicle is equal to one ounce of solution. 



DIFFUSE DISEASES OF BRAIN AND CORD 273 

subendothelial cells. This much thickens the walls of the blood- 
vessels^ and narrows and sometimes obliterates them completely. 
The other coats may also be destroyed. Periarteritis in which 
nodular gnmmata may develop in the adventitia of the vessels may 
produce globular or ovoid swellings. The interna -may or may not 
l)ecome diseased. Secondary thrombosis, softening, or rupture or 
the development of aneurysms may occur from any of these blood- 
vessel lesions. Cases where the secondary symptoms have been 
mild are particularly apt to develop syphilis of the nervous system. 
This is probably due to insufficiently treated specific disease or to 
a vulnerable nervous system, or both. 

(2) Gummata. — These may be single or multiple, and usually 
involve the pia mater, affecting the brain or cord secondarily, fre- 
quently only by compression. They spring from the walls of the 
blood-vessels, and are composed of round cells derived from them 
and from proliferated connective-tissue cells. Hence the walls of 
the blood-vessels becom.e thickened. A gummatous meningitis also 
is usually found. The gummata may be attached to the dura, and 
rarely to a vessel of the brain or cord substance proper. Gummata 
are not as commonly found in the cord as in the brain. In the 
brain they are usually seen upon the cortex or in the pons (hence 
the symptoms of palsy will depend on location of growths). 

(3) Gummatous Meningitis. — This is a condition in which the 
membranes are infiltrated with cells, and are much thickened in 
consequence. This is found always about gummatous masses, but 
may exist separately. It is more common at the base of the brain, 
and generally involves the dura. Gummatous growth themselves 
are much less frequent at the base than is specific meningitis. 

Symptoms of Cerebral Syphilis. — The onset of symptoms is 
generally from three to six years after the initial specific lesion or 
chancre. The patient will complain of drowsiness in the daytime 
and wakefulness at night, with persistent headache, due to menin- 
geal irritation and inflammation. According to H. C. Wood, he 
becomes a restless nocturnal automaton. The mental conditions 
.of obtundity, with failure of memor}^, but without delusions, are 
other distinctly psychic phenomena. Ocular palsies are very likely 
to develop early, perhaps the first svmptom being that the patient 
will complain of seeing double (diplopia) ; or it may be noted that 
he has a strabismus, or on testing the ocular balance that the move- 
ments are restricted, due to neuritis of the ocular motor nerves, 
18 



274 TREATISE OX XERVOUS DISEASES 

because basilar exudate is common. The patient is physically 
weak, the reflexes are heightened, due to the chronic irritation of 
the motor tracts and centres; and localized palsies may supervene 
in other places, such as in an arm or a lower extremity, due to 
destruction or pressure upon the motor centres. Acute optic neu- 
ritis and optic atrophy may develop, but is uncommon, while 
••' choked disk '' is but seldom seen, thus differing from eye symp- 
toms of brain tumour. The patient may develop convulsions from 
time to time in proportion as the process is chronic. Various 
paresthesia of the extremities may occur in cerebral syphilis. A 
palsy is almost never complete in this disease, and the vacillation 
from month to month is a point in favour of this diagnosis. One 
of the principal points in the symptomatology of cerebral syphilis, 
we wish to insist, is early palsy of the ocular or other cranial 
nerves. Such palsy also varies much in extent from week to week, 
according as active specific treatment is pursued or not. 

Symptoms of Spinal Syphilis. — While the symptoms are usu- 
ally conjoined with those of cerebral syphilis, still the predomi- 
nance of the spinal disease occurs in a sufficient number of cases to 
warrant the title given, and which has frequently been called, since 
Erb first well described it, Erh's paralysis. The time of onset of 
spinal syphilis is the same as that of cerebral syphilis (usually two 
to four years after infection) . An early complaint is of parassthesia 
of the lower extremities, accompanied by feebleness and a sense 
of rigidity of the muscles, with at the same time incontinence 
of urine or difficulty of urination, due to weakness of the vesical 
sphincter. Indeed bladder symptoms are the earliest symptoms of 
the disease. The reflexes are heightened, the knee-jerks being 
greatly increased, and marked sustained ankle clonus occurs. Sel- 
dom is there anaesthesia, but hyperaesthesia or hyp^esthesia fre- 
quently exists of irregular distribution, depending upon the seg- 
ment of the cord and roots involved. Some disturbance of co-ordi- 
nation and Romberg's symptom may be present. A clinical point 
of particular note is the heightened reflexes out of proportion to 
palsy and the associated proportionate diminution of muscular 
tone; so that seldom do contractures occur, even though the knee- 
jerk is wildlv spastic. The muscle development remains good; 
there is seldom wasting or fibrillary contractions, but cyanosis and 
coldness of extremities among vaso-motor phenomena are fre- 
quently seen. Bedsores or other severe trophic changes are rare, 



DIFFUSE DISEASES OF BRAIN AND CORD 275 

because all nerve-paths are seldom entirely destroyed. The non- 
symmetrical distribution of symptoms is also a special clinical fea- 
ture in syphilis of the spinal cord, as is also the remission of the 
symptoms. 

The duration is indefinite, and tends towards degeneration 
or sclerosis if not properly treated. The patient is liable to sud- 
den death, though usually the course is slow. 

Diagnosis. — Careful observation should not confound this dis- 
ease with any other malady. Confusion may be had with myelitis, 
where the symptoms are symmetrical in distribution, seldom with 
remission, while the onset is acute in character and accompanied 
by bed-sores. There are also distinct sensory symptoms, such as 
girdle sense and angesthesise, throughout the course of myelitis. 

Prognosis of Cerehro-Spinal Syphilis. — It is most hopeful of 
all organic affections of the central nervous system, excepting in 
the fulminating cases, where the profound intoxication destroys 
the nerve-cells before relief can be had through timely treatment. 
These latter cases are the rarest and do not present the typical 
features described above. 

Treatment. — This consists in vigorous and thorough appli- 
cation of antisyphilitic remedies. The use of potassium iodide, 
increased to 100 or 200 grains a day (taken in solution), will 
prove of greatest value. It is astonishing to see the good results 
obtained in the cases that have received prompt and early treat- 
ment. Where the iodide cannot be borne, or in case there be no 
response to the drug, the use of bichloride of mercury in ^V- 
grain doses, rapidly increased, is a therapeutic procedure of great 
value. Inunctions of m.ercurial ointment into the axilla and 
groins, on alternate days, will also be efficacious. During the 
administration of antisyphilitic measures the efficacy of the drug 
action may be bettered by the use of hot steam (Russian) baths 
given once or twice weekly. The stomach must be conserved in 
all cases, and if gastric symptoms occur the syphilitic treatment 
should be held in abeyance for a time and gastric sedatives and 
tonics administered, after which the specific treatment may again 
be resorted to. Eeconstructives are essential, such as cod-liver 
oil, phosphorus, and hvpophosphites. Co-pious draughts of water 
should be given, and the bowels should be kept freely open and the 
contents soluble by means of salines. The diet should be of a sim- 
ple, wholesome nature, such as eggs, milk, and other proteid food 



276 TREATISE 0^ NEEVOUS DISEASES 

in limited measure. Careful treatment of syphilis of the nervous 
system, as outlined above, persisted in for six months' time at least, 
will often produce excellent results ;, and some cases seem to be re- 
stored to normal health. If improvement does not occur within 
six months degeneration of the nerve-cells has most likely set in, 
and a favourable issue cannot then be expected, although treat- 
ment should be continued with the idea of ameliorating the dire 
effects of the syphilitic poison or toxin itself. 



CHAPTEE XVI 
GENERAL AND FUNCTIONAL NERVOUS DISEASES 

In functional nervous diseases no definite known anatomical 
change underlies the morbid alteration of function. We there- 
fore classify such affections clinically. There may be made, how- 
ever, pathogenic and etiological classifications. Thus we may have 
primary or degenerative and. secondary or acquired neuroses. 
This classification is helpful, though not perfectly correct, because 
several factors often enter into the cause of the same disease. 
Classification should not be made a fetich. 

Dana gives the following classification, which serves well in 
the majority of diseases of this nature : 



Primary degenerative neuroses 



Exhaustion and shock neuroses. 



Primary neurasthenia, hypochondriasis. 

Epilepsy. 

Hysteria major. 

Hereditary chorea. 

General spasmodic tics. 

Myotonia, 
r Neurasthenia, 
j Hysteria. 

j Exophthalmic goitre. 
[Occupation neuroses. 

f Tic douloureux. 
'Acquired degenerative neuroses. <{ Local spasmodic tics. 

(^Paralysis agitans. 



Acquired neuroses. 



Prom infectious, autochtho- 
nous, and mineral poisons. 



Miscellaneous. 



' Chorea. 
Tetanus. 
Tetany. 
Rabies. 
[ Tremor and neuralgia. 
Vaso -motor, trophic, 
and sleep disorders. 
(See appendix.) 



We shall give the most important of the general and functional 
of the nervous system, classifying them clinically, but 

077 



278 TREATISE ON NERVOUS DISEASES 

with the understanding that the cause of the disease is always borne 
in mind to be of first importance in considering its treatment. 

CHOREA MINOR, SYDENHAM'S CHOREA OR 
ST. VITUS'S DANCE 

Chorea is a general disease^ at present designated functional, 
since its aetiology is not definitely decided. An autochthonous poi- 
son, as in rheumatism or other diathetic disease, may be the excit- 
ing cause; or it may possibly be infectious in origin. Usual excit- 
ing causes are mental, moral, or physical trauma (fright, blow 
upon the head, etc.). Anaemia and general ill health and heredity 
are predisposing factors. 

Definition. — Chorea is a functional nervous disease associated 
with irregular inco-ordinate movements of the voluntary muscles, 
and accompanied by mental obtundity, anaemia, and at times car- 
diac and rheumatic S3^mptoms. 

Paralytic chorea is the name applied to that form of St. Vitus's 
dance where muscle palsy from exhaustion is markedly present. 
There is more or less paresis in all cases. 

Symptoms. — Sex bears important relation to the disease, it 
being found much more frequently in the female; perhaps the 
proportion is about two to one. Onset occurs most frequently 
between the seventh and fourteenth years. The adolescent period 
has something to do with the development of the cases occurring 
latest in this susceptible epoch. 

The first symptom is generally peevishness of the child, ac- 
companied by general restlessness, which the mother will describe 
as " fidgets." The child will drop an object without any apparent 
cause — e. g., a fork at the table, or the pencil if working at school. 
Within a week the movements will have begun in the arms, face, 
tongue, and lower extremities in the typical case. The move- 
ments are very irregular, in some cases tending to vermicular mo- 
tion, but never in any degree consistently of one type. The pecul- 
iar contortions of the face give the child a grotesque appearance, 
which with the difficulty of speech and dribblins^ of the saliva 
present the aspect of a case of dementia (facies choreica). This 
is at once unwarranted by the mental condition of the case to be 
described later. 

The gyrations become larger and increased until the range of 



FUXCTIONAL XERVOUS DISEASES 279 

movement may extend to extreme abduction of the extremities, the 
throwing about of which will prevent the child from walking or 
even sitting erect from mere mechanical disturbance. In other 
cases the palsy is so much greater than the movements that they 
are designated the '^ paretic type." In these the patient is at times 
absolutely disabled, with a few movements remaining. In other 
cases the irregular movements appear well marked and yet are asso- 
ciated with palsy out of proportion to the motor weakness. 

The movements of chorea cease during sleep. They are much 
bettered when the child is quiet, and are exaggerated on physical 
or mental endeavour. At times chorea is confined to one side 
almost exclusively, which type is termed Jiemicliorea, or one side 
of the body may be affected more than the other. Occasionally 
one upper extremity and the opposite lower will be most involved. 

The child's mental condition is below par, and while sensitive, 
the function of the mind is singularly obtunded, memory being 
poor, with inability to concentrate. In some cases there is mild 
ephemeral dementia; in other cases the dementia may go on to 
permanent mental impairment or death. In rare instances an 
excitable condition of insanity without high temperature will 
occur. 

S. "Weir Mitchell divides chorea into five types, as follows : 
(1) Those with absence of movements during rest, during some 
stage of the disease. (2) Cases in which continued movements 
are increased by effort. (3) Cases in which movements disappear 
during intentional muscular acts. (4) Cases unaltered during 
muscular acts. (5) Those in which the various types alternate. 

In violent cases the child may injure himself by tossing about, 
so that restraint is necessary. The only somatic symptom of im- 
portance is feeble and irregular cardiac action. In To per cent of 
cases a systolic mitral murmur occurs, either h«mic or due to a 
mild grade of endocarditis. 

The duration of a case of chorea is from four to six weeks. 
Severer case's may last many weeks. Recurrences are quite fre- 
quent, many cases having relapse in the spring months (March 
and April), or in the early fall (September). This is probably 
due to the effect of the changing weather as well as to overwork at 
those periods of the year. The subsequent attacks are generally not 
as long ab the primary ones, and may recur from two to fourteen 
times in as many years. 



280 TEEATISE ON NERVOUS DISEASES 

As the patient convalesces from the attack the movements grad- 
ually cease. Frequently when the paresis is very prominent the 
child complains of greater weakness and apathy than when in the 
attack. The movements cease last in the face and tongue, physio- 
logically the most sensitive parts of the body. Extreme anaemia 
will at times develop, a cardiac murmur at the base be very pro- 
nounced, and even fatty degeneration of the heart muscle be shown 
by the feeble contraction of the myocardia. In some cases oedema 
of the lower extremities will be noted. The urine is generally de- 
ficient in chlorides, with excess of sulphates and phosphates, show- 
ing the waste in the nervous system; while indicanuria is a fre- 
quent finding in those cases where gastro-intestinal fermentation 
exists, as a complicating factor in symptomatology through auto- 
intoxication. In rheumatic cases the mitral cardiac murmur may 
be very persistent, due to organic disease of the heart, which symp- 
tom may dominate in the case, and be the sequel of an apparently 
mild attack of chorea. The co-relation of rheumatism, chorea, and 
heart disease is therefore to be borne in mind; while a patient suf- 
fering from rheumatic pains with cardiac disease before or in the 
attack of chorea is a more gravely ill person than one not having 
this trio of signs. The knee-jerk is capricious in. chorea, fre- 
quently lessened, and always easily exhausted. 

Diagnosis. — Chorea minor is not likely to be mistaken for 
other diseases. Hysteria may simulate this disorder, but the ex- 
plosive nature of hysterical chorea, the larger movements, and 
less palsy will distinguish it. Hahit chorea is told by the spas- 
modic and localized character of the movements. The choreiform 
movements of the cerebral palsies are to be differentiated by noting 
the other signs in the disease in question, such as palsies, increased 
reflexes, etc. Huntingdon s chorea is difl'erentiated by its occur- 
rence in adult life and its association with, mental diseases ; also 
the hereditary nature of Huntingdon's disease. 

Prognosis. — The prognosis of chorea is good in the vast ma- 
jority of cases. A usual duration is six or eight weeks. The 
cases with cardiac affection are more apt to be prolonged, as shown 
by murmur, even if the heart disease is functional; also the anaemic 
cases are graver, due to the condition of malnutrition of the cen- 
tral nervous system in these patients. The prognosis in cases of 
organic heart disease is decidedly bad, both as to recurrence of the 
chorea and as to the life of the patient, since with each succeeding 



FUNCTION"AL NERVOUS DISEASES 281 

attack of chorea of a severe nature the systemic failure is great. 
Such patients usually die of organic heart disease (endocarditis) 
within two to five years after the original attack of chorea. The 
distinctly atrophied condition of the mucous membranes in these 
cases is shown by the fact that portions of the mucous membrane 
of the nose will be discharged en masse. In the milder cases that 
recover even after a series of attacks, the patient usually grows 
into vigorous health, no condition of' previous cardiac trouble re- 
maining in after-life. 

Treatment. — This depends upon the severity of the disease. 
The average case can be given ambulatory treatment. Physical 
and mental rest for a few hours each day is essential, as is qui- 
etude at all times, and fresh air and sunlight. The child should 
be kept away from exciting influences of all sorts, particularly 
school ; even agreeable excitement is harmful. 

The emunctories should be carefully guarded. Copious draughts 
of water between meals are indicated, especially in cases giving 
evidences of auto-intoxication. The diet should be simple, consist- 
ing largely of milk, given at stated intervals (3 to 6 ounces every 
three hours during the day) ; the patient can also be given whey, 
buttermilk, largely to act as a diuretic, junket, soft-boiled eggs, 
bread a day old, and the lighter meats, avoiding carbohydrates 
and hydrocarbons, which disturb digestion in these cases. 

In bad cases the patient should be put to bed absolutely, and 
where the movements are violent, padding about the bed should 
be judiciously done to prevent injury to the patient. Restraint 
will sometimes have to be resorted to in these severe cases. Salt- 
water sponging either with sea-water, or that artificially made by 
placing half an ounce of common salt to a quart of water, at a tem- 
perature of 100° F., will be a soothing measure, when applied by 
sponging for five minutes twice daily. Light effleurage is a meas- 
ure assisting in soothing the nervous system, as well as aiding the 
circulation and bettering the nutrition. 

Among drugs, iron is indicated. It should be employed espe- 
cially in the anaemic cases of chorea. In children the tincture of 
chloride of iron, from 10 to 30 minims, given in water, three times 
a day, is of great value. This acts as a stomachic as well as an 
haematic. The teeth should be carefully guarded from the acid, 
rinsing the mouth with a solution of bicarbonate of- soda. The 
French pill of Blaud, consisting of equal parts of sulphate of iron 



282 



TREATISE ON NERVOUS DISEASES 



and potassium carbonate, is a valuable remedy. In my experience 
this pill acts better in the older cases. The treatment of the disease 
per se is principally alterative, and no remedy acts quite so well 
as arsenic, which in the form of Fowler's solution is pleasant to 
take; also the dose can be nicely graduated to the necessity of the 
case. The usual method of administration is by giving 3 drops 
in water after meals, gradually increasing each dose by one drop, 
as shown in the accompanying table : 



BREAKFAST. 



SUPPEK. 



1st day 3 drops 3 drops 3 drops 

2d " 3 " 4 '' 3 " 

3d " 4 " 4 

4th " 4 " 4 

5th " 4 " 5 

6th " 5 " b 

7th " 5 " 5 

8th " 5 " 6 

9th " 6- '' 6 

10th '^ 6 " 6 



etc. 



etc. 



etc. 



This can be increased to 15 or 25 drops. When the physio- 
logical limit is reached the dose should be reduced one half, and 
kept at this dosage during the active course of the disease, unless 
recurrence of the arsenical symptoms are noted. In some persist- 
ent excitable cases the use of the bromides is indicated; particu- 
larly the ammonium bromide should be used, since it is less 
depressing to the heart. This salt will be found of special benefit 
in chorea with gastric irritability. Quinine, antipyrine, cimicif- 
uga, and sodium salicylate are of value in rheumatic cases. 

The cardiac symptoms should be very carefully guarded in a 
given case. Tincture of strophanthus is an excellent remedy for 
deficient compensation, and should be given in 10- to 15-drop 
doses three times a day until circulation is restored to the normal. 
Where serious organic heart disease complicates, digitalis should 
be employed. Long rest should be enjoined after the chorea has 
been recovered from. Cod-liver oil is a valuable reconstructive 
agent to be employed after the acute attack of chorea has waned. 
It is often desirable to change the scene in mild cases of chorea. 
Sea air, where high winds do not prevail, is desirable. High alti- 
tudes — above 2,000 feet — are never good for fhe patient. 



FUNCTIONAL NERVOUS DISEASES ^83 



HABIT CHOREA OR HABIT SPASM 

This is a disease of childhood, having its origin in a previous 
attack of simple chorea or developing primarily. Heredity plays 
an important part in the oetiology, as does simulation of another 
case. Children of robust physique, who have developed a simple 
chorea of very active type, or, indeed, in whom the chorea has been 
of mild form, are very apt to be those who will have a habit spasm 
remaining after the simple chorea is apparently cured. Other ex- 
citing causes of the development of primary habit chorea are reflex 
causes of many sources, such as eye-strain,^ nasal disease, binding or 
irritation of some part of the body by clothing, a phimosis, seat 
worms, deformities of speech mechanism, such as tongue-tie or 
enlarged tonsils, or anything interfering with the functionation of 
the unstable nervous system. Thus, a boy, with the predisposition, 
upon donning his first pair of ^^ suspenders " may develop shoulder 
twitching; or the child with tongue-tie may begin a contortion of 
the neck, induced by the endeavour to speak properly; or blinking 
of the eyes may result from an uncorrected astigmatism. 

Symptoms. — The parts most frequently affected in habit chorea 
are the eyelids, facial muscles, neck muscles, and shoulder-girdle 
muscles — parts particularly sensitive in their nerve supply. The 
nature of the movement is that of a spasmodic rather than true 
choreiform motion, usually excited by mental or physical endeav- 
our, although the patient can frequently control the movements in 
part by the v\dll. They are absent during sleep, but, unlike simple 
chorea, are worse when the attention is not drawn to the condition 
at all. Inhibition of the movements exists more decidedly than in 
simple chorea, in the latter of which any form of mental action 
exaggerates them. As inferred, the patient's physical vigour is 
generally excellent in cases of habit spasm. In some cases where 
it is markedly localized, as in the posterior cervical muscles, they 
may become actually hypertrophied froni overuse in these violent 
twitchings. There may be speech defects, such as echolalia, where 
sounds heard are reproduced; coprolalia, or the sudden utterance 
of profanity, etc. 

Prognosis. — The duration of the disease is indefinite, but a 
favourable prognosis can be given in proportion to the move- 
ments and the cases resulting from previous simple chorea. 
Where it develops from some other exciting cause, as peripheral 



284 TREATISE 0^^ NERVOUS DISEASES 

irritations, in my experience, the disorder is sometimes seen last- 
ing for years or becoming incurable. 

Pathology. — This is not known. Irritability of the upper 
motor neuron probably exists from some unknown poison. 

Diagnosis. — It may be confused with Sydenham's chorea. Per- 
sistency of habit spasm distinct from typical choreiform move- 
ments, also the absence of rheumatic history, are important points. 
Habit spasm from hysterical chorea is distinguished mainly by 
stigmata existing in the latter disease. 

Treatment. — This consists in getting rid of every source of 
irritation, such as by correcting eyes, by circumcision, extraction of 
misplaced tooth, removal of enlarged tonsils, or operation for 
tongue-tie, etc. If the case is the resultant of simple chorea, rest 
cure and tonics are principally indicated. Moral influence is of 
vital importance in the therapeusis. Hypnotism is a means, which, 
if it can be indiiced in the subject, is a quick agent towards cure. 
A valuable measure is to have the child stand before the looking- 
glass for three to five minutes, making an effort to control him- 
self, and in this way educate the nerve-centres to proper inhi- 
bition. Among drugs, the use of bromides, sparingly, or hyoscya- 
mus may be of value until the nerve-centres become less irritable. 
Proper resort to bathing is a valuable measure, and should be 
used. The cold shower-bath at a temperature of 60°, given every 
morning, will do much towards restoring nervous control in these 
cases, largely through establishing better equalized circulation 
within the central nervous system. 

HEREDITARY CHOREA 

Synonyms: Huntingdon's Disease or Chorea 

This is a disease beginning at about thirty years of age, more 
frequent in the male sex, and characterized by its chronicity and 
tendency to mental affection. The hereditary taint of this mal- 
ady is not always directly in the ancestry, but there is always some 
neural vulnerability or cause for degeneration, such as chronic 
alcoholism, syphilis, etc., in the immediate progenitors. The 
patient in the onset will scarcely have been seen by the physician, 
but it will be reported to him that the disposition has been chang- 
ing for some months, the patient having become nervous and irrita- 
ble, forgetful and perverse, and at times showing violent temper. 



FUNCTIONAL NERVOUS DISEASES 285 

The movements generally begin in the upper extremity, are larger 
in the gyrations than in Sydenham's chorea, the head and neck 
becoming soon affected, and with the movements of the lower ex- 
tremities the gait is particularly characteristic. The patient in his 
endeavour to walk slides and pushes one limb forward, then at- 
tempts to draw the other in its wake; then the other limb will 
be advanced in the same fashion, thus making with all its irregu- 
larity a more or less rhythmical alternation by the hampered vol- 
untary effort. The movements of the trunk become marked within 
two or three months. These may cause compression of the abdo- 
men and thorax. Occasionally involvement of the diaphragm 
produces sudden explosive sounds, similar to echolalia of habit 
chorea. The mental deterioration will have been well manifest by 
the time the choreiform movements, etc., as described, begin. This 
now consists of periods of mental depression, alternating with 
maniacal tendency, with forgetfulness, and the mental status tend- 
ing towards dementia, the patient using finally a sort of jargon in 
speaking, entirely distinct from the mechanical disturbances of 
speech which also exist, due to the involvement of the pharyngeal 
muscles. So that careful observation has to be indulged to deter- 
mine in foretelling the rapidity of downward progress of the case. 
The tendency to suicide is a characteristic symptom of the mental 
derangement. The patient's movements finally become so exag- 
gerated that he cannot walk about, the irregular choreiform move- 
ments continued during the waking state, which, however, entirely 
cease when the patient is asleep. The movements also obey those 
of simple chorea in regard to the effect of mental excitement, 
physical endeavour, etc. The movements lessen only as mental 
deterioration progresses. This in time amounts to an active pare- 
sis, the patient becoming bedridden and dying of some intercurrent 
malady. 

Duration. — The patient may be a sufferer for six or eight years 
before death supervenes, although the majority of cases are carried 
away within four or five years after its active development. 

Diagnosis. — The diagnosis of Huntingdon's chorea must be 
made between it and simple chorea, or habit chorea, or hysterical 
chorea. The age of the patient, the recovery and relapses, and 
history of rheumatism and milder grade of movements would dis- 
tinguish the simple chorea. The localized spasmodic disorder also 
occurring in children without any mental disturbances would dis- 



286 TEEATISE 0^ NERVOUS DISEASES 

tinguish the habit cases. Hysterical chorea would be known by 
other evidences of hysteria, the vacillation of symptoms, the ab- 
sence of dementia and suicidal intent, and the hysterical chorea 
being more frequent in females. 

Prognosis. — This is absolutely bad, no cases having been in 
any way permanently benefited. 

Pathology. — This consists of congestion of blood-vessels in the 
cortex of the brain and final resultant irritability and degenera- 
tion of the central motor neurones, with areas of softening in those 
cases where the symptoms and signs of paresis develop. 

Treatment. — The treatment of the disease is, as far as known, 
therefore, entirely of symptomatic nature. Supportive measures 
is the first desideratum. A simple nutritious diet, consisting of 
proteids in part, such as red meats, oysters, milk and eggs. Excess 
of carbohydrates should be avoided in all instances, and particu- 
larly in those where there is a diathetic tendency, such as to rheu- 
matism or rickets. The system should be kept well flushed with 
water to prevent the retention of autochthonous and other forms 
of poisons, particularly absorption of ptomaines from the intes- 
tinal tract. The use of iodide of potassium or salicylate of soda, in 
small doses, is indicated where uric-acid retention is suspected. 
Such nutrients as cod-liver oil and hypophosphites and the lime- 
salts are valuable adjuvants. A pill of phosphorus, y^-g- of a grain, 
or extract of chirata, 1 grain, thrice daily, are of service. Tincture 
of hyoscyamus or tincture of conium are antispasmodic medica- 
ments that are sometimes of value in controlling the movements. 
The careful use of bromides to overcome the restlessness and gen- 
eral irritability is desirable. Hypodermic injections of hyoscine 
hydrobromate, yJ-Q- of a grain, increased to -g'-g- , acts markedly well 
in cases with maniacal disposition. Patients should be constantly 
guarded as to the possibility of committing suicide, and if paresis 
becomes a prominent and permanent symptom, it will become 
essential to commit the patient to a hospital for the insane. 

CONVULSIVE TIC 

Synonyms : Tremor, or Oihs de la Tourefte\s Disease 

This is an affection characterized by large irregular choreiform 
movements, involving the face and neck, at times affecting other 
parts of the body, and which may become general. It is also char- 



FUNCTIONAL NERVOUS DISEASES 28? 

acterized by large movements, and further by peculiar mental dis- 
order. Heredity is a strong predisposing factor in this disease. 
Fright or shock is the most frequent exciting cause. By some au- 
thorities it is designated a psychosis, similar to hysteria. It usu- 
ally begins in early childhood, and is accompanied by three promi- 
nent sets of manifestations. First, the involuntary movements, 
given in the definition — these being extreme contortions of the 
part rather than any typical form of movement. The face is 
thrown into a most grotesque physiognomy. The head is rotated 
and moved about irregularly upon the shoulders. In semiclonic 
spasm the movements extend first to the shoulders, causing a spas- 
modic shrugging, depression, and throwing back of the same. The 
trunk is finally, involved in the spasm, and at length the extremities 
may be the seat of the wildest movements. All of these are exag- 
gerated by excitement or voluntary muscular effort. At times the 
spasm is so great that the patient may be thrown to the ground. 
Peculiar involuntary sounds are emitted, due to the spasm of the 
glottis and pharyngeal muscles. These echolalia or coprolalia 
may be manifested in sudden exclamations. The mental disturb- 
ance consists of morbid fears, of doubt (misophobia), of disease 
(pathophobia), etc. Morbid impulses such as erotomania exist. 
Imperative movements may be attempted, but are usually frus- 
trated by the involuntary retraction of muscles. The patient may . 
finally become extremely delusional and pass into chronic terminal 
dementia, accompanied by wasting of all the muscles. Death from 
exhaustion will then supervene. 

Diagnosis should he made from hysterical affections without 
difficulty, and would be clarified upon noting the persistent down- 
ward course of convulsive tic without the remissions of hysteria. 

Prognosis is absolutely bad, there being no instances of bet- 
terment through any forms- of treatment. The malady is an 
acute form of degeneration of the nervous system, a diffuse lesion 
being found in the central neurones, although of no definite dis- 
tribution in any particular part. 

SALTATORY SPASM 

Synonym : Jumper's Disease 

This is a neurosis allied to hysteria, occurring in early adult 
life in endemic form, often due to the simulation of other cases 
of the disease, and characterized by sudden violent spasms of the 



288 TREATISE OX XEEVOrS DISEASES 

flexor muscles of the thighs and calves in particular, which, in 
contraction, produce the typical symptoms of the disorder — a 
series of skips or jumps, keeping up for a few moments, and finally 
ending in enfeeblement or collapse of the patient, again to be 
renewed upon recovery. These remissions may occur many times 
during the twent5^-four hours, the patient after each seance becom- 
ing utterly exhausted. Then a disturbed sleep will follow the at- 
tack. But the " jumping " begins on waking. The duration of 
the attack or of the affection is indefinite. Both are pretty much 
in proportion to proper treatment instituted. Such cases quite fre- 
quently develop during religious revivals, and will disappear after 
the excitement is over. Some may die of exhaustion. 

Pathology. — There is nothing known of the pathology. Given 
an emotional subject, such irritability of the motor neurones may 
be set up by excitement ; the only clue we have to pathogenesis. 

Diagnosis. — This is made clear by observing' the endemic form 
of the disease, the peculiar paroxysms, and the hysterical mental 
aspect. 

Prognosis. — This is good. Most cases should recover. 

Treatment. — Cure depends upon the ability to gain control of 
the patient and to impress his moral and mental nature. Hyp- 
notism is a valuable therapeutic measure in this disorder, for, if 
the patient's mind can be concentrated enough to subject him 
to hypnosis, the case can generally be turned towards a rapid 
cure. The separation of the patient from the predisposing cause, 
or from others affected with the same malady, is, of course, 
to be insisted upon. Such conditions are allied to the hysteria 
observed in the northern coal regions of Pennsylvania four or five 
years ago, as investigated by Professor Xewbold, of the Univer- 
sity of Pennsylvania. 

THOMSEN'S DISEASE 

Synonyms: Paramyoclonus multiplex; Myotonia congenita; Myospasm or 
Convulsive tremor. 

It is a- congenital and inherited disease of the muscles, which 
is manifested by irregular bilateral spasmodic contractions of the 
muscles, 5 to 120 a minute, either in groups of muscles in the 
extremities, or involving all the muscles of the body. The disease 
appears earlier in life than the preceding, starting in early child- 



FUNCTIONAL NERVOUS DISEASES 289 

hood, is much more frequent in the male sex, and is of hereditary 
nature. The patient while sitting will suddenly develop violent 
spasms of a part which may be sufficient to dislodge him from 
the sitting posture, or, if in progression, may cause him to tumble 
about or fall. The muscular contractions are accompanied • by 
slight pain, but there is no tenderness over the muscles, and dur- 
ing the time of contraction they stand out in great prominence. 
The movements are generally quieted by rest, and are altogether 
absent during sleep, although the spasms themselves prevent som- 
nolence in many cases. There is not the m_ental deterioration that 
is seen in convulsive tic. 

Exercise or catching cold aggravates the spasm. 

Pathology. — Little is understood of pathogenesis, and save for 
the hypertrophy of the muscle fibres and the constant prolifera- 
tion of the muscle nuclei, nothing is definitely known of the 
pathology. The duration may be ten or fifteen years, the patient 
finally succumbing to intercurrent disease. 

Diagnosis. — It cannot be mistaken for other maladies on care- 
ful study of the above outlined semeiology. 

Treatment. — Massage, Swedish movements, and hot-water bath- 
ing are methods of relaxing the muscles. Nutritive measures, 
the hypophosphites among drugs being of value in keeping up the 
tone of the nervous system. Protonuclein may be of service 
through supplying nuclein to the degenerating muscle cell (gr. 
V, t.i.d.). 

EPILEPSY 

Definition and Etiology. — Epilepsy is a neuro-psychosis in 
which unconscious attacks and a tendency to convulsive seizures 
are permanent features of the disorder. The disease is well known 
to be hereditary as to the degenerative predisposition ; and it will 
frequently be found "that where epilepsy has not existed in the 
previous generation there will at least be a history of alcoholism 
or specific disease in the ancestry. The disease may occur at any 
period of life. In those more truly hereditary cases (75 per cent) 
it begins quite early, before the tenth year. The sexes are about 
equally affected. It can be pretty positively stated, the more ad- 
vanced the age at the development of the disease in the so-called 
idiopathic case, the less likelihood of heredity being an astiological 
factor; but up to the degenerative period of life, when inhibition 
19 



290 TEEATISE ON NERVOUS DISEASES 

*is less stable, epilepsy may appear as real stigmata of a degenera- 
tive tendency. Other causes of epilepsy are mental shock, injury 
to the head, such as fractures, concussion or compression of the 
brain, meningitis, brain tumour, gunshot wounds, toxaemias (alco- 
hol, lead, diabetes, urasmJa), reflex irritation (eye-strain, phimo- 
sis, nasal or intestinal disease), and circulatory disturbances. Cor- 
tical apoplexy or meningeal haemorrhage is not infrequently the 
fundamental cause of the epilepsy coming on, due to insuperable 
obstacles at birth; and in such cases the epileptic disease is but a 
symptom of the cerebral palsy of childhood. This is well marked 
in the case of a boy under the writer's care who is spastic, has a 
dolichocephalic head, has had convulsions since babyhood, and has 
from three to ten attacks of grand mal daily. He frequently suffers 
from post-epileptic palsy. Hydrocephalus is a cause of epilepsy. 

Diagnosis and Symptoms. — Epilepsy is divided into major 
{grand mal) and minor attacks {yetit mal). 

Major epilepsy is divided into focal or Jacksonian, where the 
spasm is limited to a part or member of the body, or where the 
convulsive seizure begins locally. There are also general epileptic 
convulsions. Where the disease is well established there is present 
a peculiar physiognom}^, one of mental depression and instability of 
purpose; also acne on the face, as a rule, the result of prolonged 
use of bromides — the so-called epileptic fades when associated 
with the features of mental instability mentioned. 

Premonitory symptoms frequently precede the attack. These 
consist of headache, giddiness, jerkings, mental depression or ab- 
erration, etc., and may occur for some hours before the attack. 

The attach may be ushered in by a peculiar subjective sensation 
called an aura', usually a glolus or a feeling of depression, as of a 
cloud coming over the patient, the vision becoming dull, and in a 
moment passing into the convulsion. There are many aurae. 

Sensory Aurce. — The aura may also be a pain in the epigas- 
trium — gastric aura; or rarely, it may be of parjesthesia in an 
extremity; or less frequently, an hallucination of smell or taste 
or hearing or sight. I have known a case where the odour of 
violets preceded the attack; another in which the sound of the dis- 
charge of a gun was the hallucination; while irregular scotoma 
or the seeing of some grotesque object may be the visual disturb- 
ance preceding the seizure. Motor aurae as a marked tremor may 
occur. Following this there may or may not be irregular auto- 



FUNCTIONAL NERVOUS DISEASES 291 

matic movements in different parts of the body, the patient quickly 
becoming pale, then cyanotic and unconscious. In the light 
attack {petit mal) the patient may, with or without this precedent 
phenomena, pass into unconsciousness, accompanied by dilatation 
of pupils, and if at table, dropping the fork or some other object 
— the spell lasting but a few seconds, when the patient may resume 
his usual condition. The attack may be succeeded by somno- 
lence or sound sleep lasting a half hour or more. In case the 
attack is one of grand mal succeeding the premonitory signs 
already mentioned, or with the initial cry in most cases, due to 
the firm rigidity of muscles of the chest, the patient falls over 
unconscious and goes into a general convulsive seizure, consisting 
of tonic rigidity followed by clonic spasms accompanied by froth- 
ing at the mouth and conjugate deviation of the eyes up and out 
towards the side of most violent movements; also dilated pupils. 
Blood may also be seen coming from the mouth, due to biting the 
tongue in the attack. The convulsion finally ends by rigidity of 
the flat trunkal muscles, and within a minute or so the entire 
attack is completed, there being rather sudden restoration of con- 
sciousness and of power in the extremities, although the intellect 
remains especially dulled for some moments, and there may be 
transient aphasia. The patient here again is apt to go into som- 
nolence, which may last half an hour, or several hours in rare cases; 
but exceptionally post-epileptic paralysis may occur or automatic 
acts, the patient going about without mental control or apprecia- 
tion of his surroundings. In an attack the patient usually suffers 
vesical or rectal incontinence, or both. 

Occasionally " masked epilepsy " or substitution phenomena 
take place of the attack per se, the patient passing through auto- 
matic acts instead of a convulsion; or a condition of double con- 
sciousness may exist in which the patient may wander off for some 
hours or days, " coming to himself ^' in a remote locality. This is 
termed ambulatory epilepsy. Rarely, too, some marked psychosis 
may be the substitution, as a mania or delusional insanity with 
homicidal or suicidal tendencies. If the attacks follow one upon the 
other in rapid succession, we have what is termed status epilepticus, 
and in such condition the patient may actually die of exhaustion. 

The epileptic complains of soreness and pain in the limbs after 
a seizure, and the body mav be bruised or dislocations occur from 
the movements or in the falling at the beginning of the attack. 



292 TREATISE OX NERVOUS DISEASES 

Convulsions occur more frequently in the early morning hours 
when the patient is asleep; this is probably due to the lowered 
physiological ebb of the nervous system at this time. In chronic 
cases this rule will not be maintained; the patient will have the 
attack at any part of the day (diurnal) or hour of the night. If it 
be nocturnal epilepsy, frequently the patient is not aware of the 
attach except for the soreness in the muscle. Intercurrent diseases 
or pregnancy may stay attacks for the time being. 

Gowers mentions the following as the chief characteristics of 
petit maly arranged in the order of frequency : 

1. Sudden momentary unconsciousness, or " fainting/' or 
" sleepiness," without warning. 

2. Giddiness. 

3. Jerks or starts of the limbs, trunk, or head. 

4. Visual sensations or loss. 

5. Mental state: Sudden sense of fear, etc. 

6. Unilateral peripheral sensation or spasm. 

7. Epigastric sensation. 

8. Sudden tremor. 

9. Sensations in both hands. 

10. Pain or other sensation in the head. 

11. Choking sensation in the throat. 

12. Sudden scream. 

13. Olfactory sensation. 

14. Cardiac sensation. 

15. Sensation in nose or eyeball. 

16. Sudden dyspnoea. 

17. General "indescribable" sensations. 

After these attacks patients may perform automatic actions, as 
after attacks of grand mal. Eating at times induces attacks re- 
flexly. 

Convulsions usually sooner or later develop, and the two forms 
often coexist and interchange in the nature of attacks. In either 
form of epilepsy there is excess of leucocytes and poikilocytes. 

Diagnosis. — Epilepsy may be confused with the hysterical 
paroxysm in rare cases. In hysteria there are stigmata of the 
disease, such as reversed colour fields, hystogenic zones, etc.; and 
the attack itself is prolonged a half hour or more, the spasms 
being more irregular and tonic in character. The patient bites 
the lips rather than his tongue. The eyelids are kept closed. 



. FUXCTIOXAL XERVOUS DISEASES 293 

The pupils are not dilated. Syncopal attacks may resemble petit 
inal. Careful study of the circulation will differentiate. 

Puerperal convulsions are told by the histon- of the case, the 
finding of albumin in the urine, and the more prolonged series 
of conrulsions. Other symptomatic epilepsies are easily diagnos- 
ticated. Myoclonic epilepsy is told by the preceding myoclonic 
state of the muscles. 

Pathology. — This is most likely a subtle anatomic or physio- 
logical affection of the cerebral cortex in all cases, though careful 
search in the majority of so-called idiopathic cases fails to reveal 
any changes by our present methods of research, which only goes 
to show our profound ignorance of this enigmatic disease. If a 
patient dies in convulsion, venous engorgement and minute haem- 
orrhages may be found in the cortex. Diffuse sclerosis of the 
cortex has been found (tuberculous or otherwise), meningo- 
encephalitis. Fere has frequently found neuroglear prolifera- 
tion, while Marenesco and Block have described vascular and peri- 
vascular changes in the cortex. H^i^ertrophy of neuroglear bun- 
dles between pia and cortex is very frequent. Organic epilepsy wiU 
have as its pathology the pathology of the causative disease. 

Prognosis. — An axiom in prognosis of epilepsy is, that the 
younger the case the worse it is for help or cure: the older the 
person, per contra, the greater hope for amelioration or recov- 
ery. Among the latter class we have subdivisions: first, cases in 
which mental degeneration takes place rapidly; and secondly, 
those where the attacks do not seem to produce any great mental 
depreciation. Xapoleon's case was an example of this class. 
Focal epilepsies are pretty positively due to some definite organic 
lesion. In proportion as the cerebral cortex itself is involved will 
surgical aid fail of relief. But where such lesion is operable, as, 
for example, a localized meningeal lesion or depressed fracture, 
operation at the earliest moment will be fraught with relief or 
cure in 15 per cent of cases. Afier five years surgery cannot help 
epilepsy, since the habit has been too deeply established. In pass- 
ing, it should be stated that extradural haemorrhage in the newly 
born ought to be treated surgically, if sequent epilepsy from a 
secondary irritation is to be avoided in later life. Such surgical 
procedure has as yet never been done, but has been suggested by 
Dr. S. "Weir Mitchell and Dr. W. W. Keen. As refinements of 
diagnosis become more and more accurate in the new-born will the 



294 TEEATISE OX XERYOUS DISEASES 

possibility of such help from the surgeon be determined. Spon- 
taneous cures rarely occur. If attacks have lasted two years, there 
is little hope of cure in '"' idiopathic " cases. 

Treatment. — The above-indicated surgical treatment we most 
earnestly commend in early cases of the disease where there is any 
evidence of dural hsemorrhage, or other foreign body causing irri- 
tation of the cortex. A child with epilepsy should be subject to 
most rigid scrutiny for evidences of reflex irritations. Gastro- 
intestinal disorders, including those due to parasites, as the nema- 
todes or trematodes, should be eradicated by first expelling the 
offending parasite. The use of depresso-motors is indicated in 
epilepsy, since there is excitation of the motor cortex; such symp- 
tomatic treatment is, of course, to be desired in itself, and these 
drugs do much good in this disease. Ten to 15 grains of the 
bromide of potassium should be given three to four times a day, 
according to the age of the patient and the physiological idiosyn- 
crasy. In giving the bromides, they should be continued for a 
month or two, when, even if the attacks are stayed, it is wise to 
withhold the drug for a week, then to continue with small doses, 
gradually getting up to the maximum, as mentioned. The opium 
treatment of epilepsy, which consists in the gradual increase of the 
drug up to producing stupor in the patient, has been commended 
by Collins in this country and by Flechsig and others abroad. 
The tendency to disturb the stomach of the patient or to produce 
the morphine habit seems to me a strong contra-indication against 
the use of the drug ; although I have seen a hypodermic injection 
of morphine sulphate given during an epileptic status quiet the 
patient and prevent further seizures for the time being. The use 
of cannabis indica will be found of value in cases of petit mal. 
The berries of the horse-nettle or Solarium carolinense, especially 
in the form of the fluid extract, I have found beneficial in a num- 
ber of cases of idiopathic epilepsy where there is no hereditary 
taint. A fluid extract of the drug is particularly serviceable if 
made from fresh berries, the drug being pushed to the full physio- 
logical limit. At present in a case under this form of treatment, 
after all other methods have failed, a fluid extract of the berries, 
pushed to a dram four times a day, has prevented an attack for 
three months, whereas the girl had been havinsr them previously on 
an average of one attack every ninth day. Belladonna is occasion- 
ally a useful remedy, especially where the circulation seems to 



FUNCTIONAL NEEVOUS DISEASES 295 

have failed through vaso-contraction ; this in conjunction with 
nitroglycerin, given in continued dosage, will sometimes act 
favourably in allaying the spells. The use of digitalis in combina- 
tion with the bromides has controlled attacks in many cases with 
feeble heart circulation, where the bromides alone had failed. The 
reason of this lies perhaps in the better circulation produced in the 
brain, as well as in the more active circulation carrying off waste 
products. In all cases of epilepsy the gastro-intestinal tract should 
be particularly guarded. If indican be found in excess in the 
urine, especially is it important to use intestinal antiseptics, such as 
salol, grains 2 to 4, in twenty-four hours ; also high flushings of the 
colon with lime-water solution, an ounce to a quart of tepid water. 
If there be gastric dilatation, lavage of the stomach will frequently, 
by preventing absorption of undigested food products into the 
blood, produce happy results. Eegulated exercise is essential. 
The mind should be lightly employed. Special care should be 
given to massage and the hygienic condition of the skin ; salt bath- 
ing is particularly desirable to stimulate cutaneous circulation, and 
to the full extent relieve any congestion of the meninges. Tou- 
louse speaks of the value of withdrawing common salt from epi- 
leptics, thereby permitting free absorption of the bromides. Dis- 
turbed metabolism, especially the uric-acid diathesis, calls for 
careful attention ; and in the latter class of cases the use of alkaline 
waters is to be commended. Milk diet, or at least the withhold- 
ing of meats and indigestible foodstuffs, is important. The worst 
cases are better treated in the colony farms, as at Sonyea, N. Y. 

NEURASTHENIA 

Synonyms: Nervous exhaustion; Nerve tire; Nervous prostration; Beard's 



Definition. — This is a functional disease in which there is a 
condition of irritability with weakness of the central nervous sys- 
tem. It was first described by Beard, of New York, in 1869. The 
age of onset is usually between eighteen and thirty years. It is 
more frequent in women (75 per cent of the cases), more persistent 
when occurring in the male. The disease is hereditary or acquired. 

Causes. — Overwork, worry, hereditary predisposition, poisons, 
autoinfections, and fright. Other predisposing causes are anae- 
mia and sedentary habits, lack of exercise, unhygienic surround- 



296 



TREATISE ON NERVOUS DISEASES 



ings, absence of sunlight, improper food, and genital disease, par- 
ticularly in women. (See Fig. 64.) 

The communications of the nervous system to the genital 
organs may be better understood by the following diagram: 



Spinal cord. 




Plexus ischiadicus Plex.pudendaliS Plexus coccygeus Plexus deo-inguinal. . plexus genito crural. 



N.n. tiemorrh,. 
{Nerves of lower \ \ 

extremities) » 



JV. pudend. 



N. sperm'Ant. N. lumbo-inguinalis 



I " 

Ni^perinealis I N. dorsal clit. 
\ • 

\ ' 

Flextis aavernosua {clitoris) 



Branches to uterus 




Plexus vesico-vaginalis 
{Bladder and vagina) 



Plexus utero-vaginalis 
I {Uterus and vagina) 



Ptexus spermat {ovaries, tubes 
and fund, uteri) 



Plexus renalis {ovaries) 



Plexus Cceliacus 

Fig. 64.— Communications of the Nervous Ststem to the Genital Organs. 
Dotted lines indicate combinations. (Pearce-Beyea.)i 

From this description it is definitely shown that there is an 
anatomical relation between the female genitals and the nervous 
system, and it would seem that there must be, at least in some 
measure, a communication between certain physiological functions 
and diseases of the female genitals and the nervous system; and 
also, therefore, to some diseases of the nervous system. 

Symptoms — Psychic. — Generally an irritability of the mind, 
lack of power of concentration, f orgetf ulness and inability to carry . 
on a continuous line of thought; peevishness, and supersensitive- 



1 The Memphis Lancet, September, 1898. 



FUNCTIONAL NERVOUS DISEASES 297 

ness, with insomnia. The patient complains of vertigo. Photo- 
phobia or other special sense irritability may be manifest. The 
bladder may be " irritable " and an early symptom. 

Sensory. — Peculiar sensations exist as of heat and cold, paraes- 
thesia of the extremities, or actual hypersesthesia. There are 
usually tender "spots on pressure over the spinal column, princi- 
pally over the cervical, dorsal, and lumbar enlargements of the 
cord. The patient complains of a sense of constriction about the 
head, a vague feeling of distress, often described as a ^^helmet- 
like " headache. The pain may be localized particularly in the 
frontal and occipital regions. It is made worse by use of the eyes 
and by mental or physical work. Backache is constant. 

Motor. — These consist of a fine tremor of the extremities, and 
tongue, and lips. The tremor is brought out by intention. It 
is apt to subside when the patient is quiet in the milder cases. 
The muscular tone is lessened, fibrillary contractions of the mus- 
cles may occur, especially if tapped with the percussion hammer, 
that may bring this phenomenon out enough to simulate the fibril- 
lary contraction of degenerative states, as in chronic poliomyelitis. 
There is widespread enfeeblement of the musculature. The patient 
tires on the slightest exertion, but there is never palsy or convul- 
sion. The reflexes are heightened. Weakness is worse before noon. 

Vaso-motor palsy and leakiness of the skin with cold extrem- 
ities is frequent. Palpitation of the heart is not uncommon. The 
urinary secretion is usually increased and of low specific gravity, 
with excess of phosphates. Indicanuria is very general in cases of 
gastro-intestinal origin. Colliquative diarrhoea is a commoii 
symptom, although it may alternate with persistent constipation. 
The patient often complains of tympanites, borborygmus, and 
tenesmus. Hyperchlorhydria is not uncommon, and is especially 
marked after a meal. In some cases there is distinct gastrectasia. 
Displacements of the abdominal organs will be found in a few 
cases of neurasthenia; thus floating kidney is not a- rare occur- 
rence; displacement dov/nward of the liver we have seen, due 
entirely to the relaxation of its ligaments. The occurrence of 
abdominal pain in the right, lower quadrant o± the abdomen is 
undoubtedly due to a fermentation in the c^cum, and while some 
cases have been mistakenly diagnosed appendicitis, it is possible 
that neurasthenia may be responsible in this way for that disease 
in a few instances. 

PatJioIogy. — There has been found by Hodge granular change 



298 TEEATISE OX NERVOUS DISEASES 

of the cytoplasm of the neurone, following induced exhaustion, in 
bees. This is accompanied by a diminution in size of the cell, 
but without actual degeneration; the incipient pathologic state 
being recovered upon the restoration of the bodily function. In 
the human body it is likely that this same change occurs, which 
has, however, not been actually demonstrated as yet. 

Adjunct pathogeneses of neurasthenia are circulation of the 
blood to the cerebral cortex, of toxines, alloxuric bodies, uric acid,^ 
and allied by-products. The deficiency of excretion of solids by 
the kidneys in a few cases may be the exciting cause for the de- 
pression of the nerve-cell, and, therefore, induction of active 
symptoms of nerve exhaustion. 

Diagnosis. — Neurasthenia is to be told from hysteria, in the 
latter of which the emotional state of the patient is the salient 
point. In the hysterical person, too, there is no muscle hypotonia, 
as in nerve exhaustion; perversions of common sensation, paraly- 
sis, or convulsions being frequent symptoms in hysteria. The 
inconsistent s3nnptomatology is a vital point in determining 
hysteria. Asthenias following prolonged fevers are to be distin- 
guished from neurasthenia pe7' se, since in these symptomatic 
disorders the patient has not the particular irritable symptoms 
already mentioned. 

Secondary neurasthenia is to be told from primary or essen- 
tial neurasthenia by finding a reflex source of irritation for the 
former, such as uterine diseases, phimosis, or sexual disorder in the 
male (the so-called sexual neurasilienia). Neiir asthenia terminalis 
is the chronic form that has become incurable. 

Prognosis. — The prognosis of acute neurasthenia is good if 
treated at once, depending upon the non-hereditary tendency of 
the patient. Cases with the hereditary taint are to be given a 
guarded prognosis. Cases of secondary neurasthenia will also re- 
cover promptly in proportion to the relief of the primary exciting 
cause, such as a proper repair of cervical and perineal tear with 
prolapsus uteri; the correction of errors of refraction, etc. 

The duration of the average case of simple neurasthenia is 
about three months. Chronic cases may last for years, with re- 
missions of periods of several months, or longer. 

Treatment. — Revolution in the treatment of nervous exhaus- 

1 See Laboratory Studies on Uric Acid in Neurasthenia, etc., American 
Journal of Insanity, vol. Iviii, No. 1, 1900, 



FUNCTIONAL NERVOUS DISEASES 299 

tion was made by Weir Mitchell in 1874, when tha different meth- 
ods employed in treating this disease with more or less success 
were correlated and established into guiding principles. These 
consist of (1) mental and bodily rest, (2) full feeding, (3) isola- 
tion, (4) massage, as well as movements, and (5) electricity. The 
employment of this combination is designated the " rest cure." It 
should be carried out for a period of six or eight weeks to three 
months. If good results are not obtained at the end of three 
months, experience teaches that it is useless to continue the treat- 
ment. It is essential, in carrying out the method, to remove the 
patient from home, or, if this cannot be, to a remote portion of 
the house, away as far as possible from the atmosphere of home. 
The patient is kept absolutely in bed and given two good nurses, the 
room being kept at an even temperature, at an average of 68° F. 
All reading is to be discontinued, and even the nurses are in- 
structed to converse but little over pleasantries of the day, and 
none as to the patient's vagarious complaints. The instructions, 
which should be explicitly written by the physician, are further 
as follows: Patient put on a light milk diet, a glass being given 
at seven o'cloclj in the morning, on waking, and then every two 
hours during the day; thus from 9 to 10 doses of milk will be 
given the patient in twenty-four hours. Beginning at first 
with 3 ounces, finally reaching 8 to 10 ounces, which would make 
27 to 72 ounces taken within the twentv-four hours. At any 
time the patienf s stomach rebels the increasing dosage of milk is 
held or lessened, or lime-water or peptonization may be employed 
to assist digestion. In addition to this dietary the patient may 
take at 7.30 o'clock in the morning a cup of cocoa, which can be 
repeated at eight o'clock at night. If there is persistent insomnia, 
and the stomach is not being taxed for digestion too severely, a 
piece of dry toast can be given in the evening with the glass of 
milk to vary the monotony, although it will be found, in the aver- 
age cases suitable for this treatment, that large quantities of 
milk can be taken without causing any disturbance. The milk 
diet is continued for three or four weeks, and when the patient 
is gaining in weight the diet can be increased to solids, such as 
pToteids, in the shape of red meats and oysters, lamb chops, eggs, 
etc. At this stage it is also well to add a nutrient, as the fluid 
extract of malt, of which there are several varieties on the market, 
the Johann Hoff malt being one of these. 

As regards rest, the patient is not even allowed to sit up, 



300 . TEEATISE OX XERYOUS DISEASES 

except for the moment of taking the food, which should be admin- 
istered by the nurse. Sot is the patient permitted to read. 

The patient should be given a tepid sponge bath, followed by 
an alcohol rub in the morning, and an alcohol nib alone at 9 p. m. 

The braiding of the hair and general toilet should be left en- 
tirely to the nurse. These little details are essential in the proper 
carndng out of the rpgime. if good results are to be obtained. 

The massage should be given at about 10 a. 3I., beginning at 
first with light effleurage, finally reaching the deep kneading of the 
muscles, which is of most value in their nutrition. This also as- 
sists digestion of so large quantities of food. It is interesting to 
note the relation of food supply to the proper massage and Swedish 
movements in a rapidly progressing cure under the rest treatment. 
Electricity usually is best in the form of faradism, the nurse em- 
ploying it at about three o^clock in the afternoon, as follows : The 
extremities are first given the rapidly interrupted current, then the 
slow interrupted current is applied to the muscles of the upper 
extremities, lower extremities, abdomen, pectoral region, erector 
spine, and back group of muscles. (See Massage and Electricity.) 

Wlien the patient has gained in weight and in general nervous 
health she is gradually got out of bed, which should first be by 
sitting up in bed for five minutes at a time, gradually increasing 
this to twice a day, and finally the patient is to be lifted upon a 
chair. The length of time is increased until sitting up two or 
three hours, morning and evening, has been indulged. The patient 
can move about the room and then get back gradually to normal 
life — a renewed person. As a rule, improvement continues for 
many weeks after the case has been so treated. 

The so-called partial-rest treatment consists in having the pa- 
tient rest for an hour or so in midday, plus the hour's rest after 
the massage in the morning, the rest of the day being devoted 
to quiet living, when the patient may do a certain measure 
of work, if not of a taxing nature. The diet in partial-rest 
cure is never limited to milk alone, and malt is given with the 
meals. Frequently the use of phosphorus in pill form, yJ-q 
of a grain and a capsule ; of extract of chirata, 1 grain : extract of 
ignatia, ^ grain, to be given after meals, will be of value. The 
simple elixir of iron, quinine, and strychnine is useful in the 
cases among the poorer classes, and reaches many of. the indica- 
tions.^ In any case of neurasthenia the bowels should be kept 

^ See Appendix. 



FUXCTIOXAL XERVOUS DISEASES 301 

soluble. For this purpose the Lady AYebster pill or the pill of 
aloin (gr. ^), belladonna (gr. yV)? and strychnine (Vo) may act 
nicely when given at bedtime. The fluid extract of cascara, in 
from 15- to 30-drop doses, is a valuable remedy in these cases. 
Where there is acidity of the stomach the phosphate of soda, in 
dram doses, on waking, will prepare the stomach for better 
digestion. In this case the pill of nitrate of silver (gr. -|), given 
three times a day, will be of service as a tonic to the mucous 
membrane of the stomach. 

Hydrotherapeutics in neurasthenia is very important, and 
should be used as indicated, by sponging in rest-cure cases or apply- 
ing cold douche in ambulatory cases. The Charcot's douche is one 
of the most valuable methods of applying water, and consists in 
the circular spray applied to the trunk, chiefly over the spinal col- 
umn. In hydrotherapeutic procedures for neurasthenia it is best 
to begin with a tepid sponging or a few moments' bath of the body 
accompanied by frictions, and at the end of five or ten minutes 
follow this up by a cool spray, at a temperature of 65° F. This 
entire procedure is to be followed by a brisk rub with a Turkish 
towel and rest for half an hour afterward. Flushings of the colon 
with tepid water every other day is valuable in those cases of an 
autotoxic nature. The use of warm mud-baths, such as the 
" fango " of the Mediterranean, I have seen do good in cases ac- 
companied by the most persistent insomnia. Where there is an 
irregular excretion of uric acid, especially in rheumatic diatheses, 
the use of salicylate of soda will be found of value in relieving the 
general irritability of the patient and painful headaches, probably 
due to by-products circulating in the meninges. The correction 
of the eyes should be had in cases of reflex ocular defects. All 
sources of irritation should be eradicated, as phimosis, etc. The 
gynaecologist is here closely related to the neurologist, and while 
too many cases of neurasthenia are assigned as gynsecologic, it 
must be stated that judicious study of neurasthenia, following 
childbirth, will determine it to be caused or aggravated by some 
lesion of the pelvic tract. Other measures to be employed in 
neurasthenia are fresh air, sunshine, and salt breezes. Iron should 
be employed in anemic cases. Good food must be had at all 
times. Hypernutrition is an essential in the treatment of this 
disease. The patient should be encouraged at all times. 

The climatcrlogy of neurasthenia is not. sufficiently worked out 



302 



TREATISE ON NERVOUS DISEASES 



at the present time. It would seem axiomatic at all events that 
the patient should not ascend to an altitude above 2,000 feet. 
A very stimulating climate should be avoided, as should also dis- 
tricts menaced by fogs, cloudy, saturated atmospheres, with but 
slight movements of air currents, and the opposite, high-wind 
localities. Sea level, with continuous heat, non-varying, is bane- 
ful. Thus the Bermuda Islands and Florida are enervating local- 
ities. Ideal conditions for the neurasthenic patient include sea- 
air in a well-wooded country, far enough from the coast to avoid 
its fogs. Sea voyage is, as a rule, an .excellent preliminary to other 
climatic measures, and, provided it is not stormy, will act both 
psychically and physically in soothing the nervous system. 



HYSTERIA 

This is a functional disease of the nervous system, manifested 
by psychic (emotional), motor, and sensory phenomena. 

This disease has been the cause of much discussion as to its 
entity, and to many other misunderstandings in the progress of 
medicine than any other malady. It is the old ^' possessions '' 
of the middle ages; in common-sense garb to-day a disease of 
emotions. 

Etiology. — Heredity is distinctly a cause of hysteria. Next in 
order would come moral shock, physical shock, and overwork, and 
sudden drain upon the system, as in acute anaemia, typhoid, etc. 

Symptoms — Psycho-sensory. — These are predominating, being 
somewhat m.asked in certain cases, and therefore misleading in the 
differential diagnosis. There are two types of hysteria: the gen- 
eral state associated with stigmata, and the paroxysmal. 

The following table from Gowers illustrates the differences 
between epileptic and hysterical paroxysms : 





EPILEPSY. 


HYSTERIA. 


Apparent cause. 
Warning, 

Onset, 

Scream, 

Convulsion, 


None. 

Any, but especially unilat- 
eral or epigastric auras. 

Always sudden. 

At onset. 

Ri2:idity, followed by 
jerking, rarely rigidity 
alone. 


Emotion, 

Palpitation, malaise, chok- 
ing, bilateral foot aurae. 

Often gradual. 

During course. 

Rigidity, or "struggling," 
throwing about of limbs 
or head, arching of the 
back. 



FUXCTIOXAL NERVOUS DISEASES 



303 





EPILEPSY. 


HYSTERIA. 


Biting, 


Tongue. 


Lips, hands, other people 
or things. 


Micturition, 


Frequent. 


Xever. 


Defecation, 


Occasional. 


Never. 


Talking, 


Never. 


Frequent. 


Duration, 


A few minutes. 


More than ten minutes, 
often longer. 


Restraint necessary, 


To prevent accident. 


To control violence. 


Termination, 


Spontaneous. 


Spontaneous or induced 
(water, etc.). 



Among stigmata of hysteria there is the emotional element of 
the patient, the lack of control of will power, which is induced the 
more by any slight excitement, particnlarly of a psychic nature. 
Narrowing of the visual fields and reversal of the colour fields 
(red being perceived before blue) is frequently found in hysteria. 
Hysterical amblyopia or hysterical blindness is a very rare symp- 
tom. The patient is able to escape objects in walking about, but 
has no conception of their shape, size, or use. There may be 
photophobia, achromatopsia, or dyschromatopsia. 

Other psychic special sense symptoms are the following: Hy- 
perosmia, anosmia, and parosmia; in the ear we have similar con- 
ditions — deafness, increased acuity of sense of hearings tinnitus 
aurium; the sense of taste may be affected — h3'pergeusia, ageusia, 
and parageusia. Hysterical hyperpyrexia may occur. 

The so-called hysterical zones are frequently found on pressure 
over the dorsal, cervical, and lumbar regions of the spine, also 
over the ovaries and beneath the breasts — hjsferogenous zones. 

Other sensory disturbances may be geographical or segmental 
or glove-like areas of anaesthesia, or a very sharply defined hemi- 
anaesthesia. This is quite distinct from organic hemian^esthesia, 
where the loss of sensation passes beyond the median line — due to 
interdigitation of nerve-fibres from each side upon the skin be- 
yond the median line. Hysterical joint is a rigid, tender joint. 

The subjective sensation of tingling in the extremities (paraes- 
thesia) is very usual in hysteria. At times this takes on the hal- 
lucinatory expression of ants creeping over the body, and it is 
very difficult to convince the patient that this is not so. 

Motor} — The motor symptoms of the continuing state of hys- 
teria are, as a rule, of excessive muscular action, with irregular 

^ Hysterical ataxia may occur. Astasia-abasia is inability to stand or sit 
well in hysteria. 



304 TREATISE OX NERVOUS DISEASES 

and rapid movements of the extremities in any particular voca- 
tion. Tlie depressive motor states do exist, however, in the minor- 
ity of cases, where the patient is apathetic, inactive, or even seden- 
tar}^, with or without actual palsy. Catalepsy or trance may per- 
sist for days. Palpitation of the heart, rapid breathing, excessive 
or deficient secretion of urine, or even haematuria, may exist in 
hysteria. Dysmenorrhoea and amenorrhoea are not uncommon. I 
have not observed any particular alteration of the function of the 
bowels in hysteria, although regurgitation of food or even merycis- 
mus and extreme tympanitis (phantom tumor) are very usual. 

The paroxysmal stage of hysteria consists particularly of vio- 
lent motor manifestations, which, as a whole, is described as the 
attack of hysteria. In this the patient will, after some hours of 
premonition, of which he will give ample warning, pass into local 
and general convulsions, which will assume the tonic type in par- 
ticular, the patient in her contortions being drawn into opisthot- 
onus or pleurothotonus. The movements of the extremities are 
more or less vermicular, rather than of true clonic or tonic type. 
The eyes are rolled about, although the lids are generally kept 
closed, and it will be found that the pupils are not dilated, as in 
epilepsy. The patient will not injure herself as a rule, and falls 
in the attack upon some convenient spot. While there may be 
frothing at the mouth, there is never biting of the tongue, nor the 
characteristic cry seen in epilepsy. The attack is noted for its 
dramatic effect, and continues the more when the patient is in 
special solicitude by her friends. An " attack " of hysteria may 
last from five to ten minutes to several hours or longer, the 
patient usually passing out of the condition suddenly, and may 
from sheer exhaustion fall into sleep or a state of trance lasting 
some hours. The patient is not unconscious in the attack, and if 
pricked with a pin or otherwise irritated will frequently resist 
and give evidence of the disturbance. 

Certain passionate attitudes are described by the French in the 
" grand '^ attack ; these are seldom found in America. They are : 

1. Epileptoid. 

2. Grand movements. 

3. Period of passionate attitudes. 

4. Period of delirium. 

The attack may last twenty minutes or as many hours. 
Diagnosis should not be confounded with other diseases, ex- 



FUNCTIONAL NERVOUS DISEASES 305 

cepting possibly with neurasthenia, where the emotional element 
is wanting; but it must be remembered that the two diseases coex- 
ist. Hysterical manifestations occurring as symptoms of brain 
tumour should be borne in mind, and careful search made in all 
cases for the symptoms in the latter disease. Hysteria is very apt 
to be diagnosed in some cases of tumour of the frontal lobe, and 
in this class of cases the most mistakes are made. 

Prognosis is always good as to the paroxysm, and to be cau- 
tiously given in cases hereditary in type. In acquired hysteria, 
where the initial cause has been eradicated and impression has 
not been made too profound upon the nervous system, recovery 
will frequently occur after proper treatment. 

Treatment. — This consists of psychic influence largely. Such 
patients should be got entirely under the control of a physician, 
away from sympathetic friends, and firmly, though gently, 
treated. Encouragement should be given when the patient con- 
trols herself, thereby strengthening the will power, which is so 
deficient in this disease. If the system is run down, a tonic line of 
treatment must be enjoined. Change of scene is frequently neces- 
sary, a long sea voyage being desirable where there has been a great 
moral shock as the exciting cause. 

Among drugs bromides are indicated; asafoetida, gr. v, in pill 
form; or a compound sumbul pill of Goodell, ext. sumbul, gr. j; 
ferri. sulph. exsic. gr. j ; asafoetida, gr. ij ; acid, arsenicum, gr. -^^ 
given thrice daily. In the attack the administration of aromatic 
spirits of ammonia, valerian, or cold douches to the face will he of 
value. Hypodermic injections of plain water, or where the con- 
vulsion is serious small doses of morphine, guarded by atropine, 
will be indicated; or a cold plunge may be given. 

Counter-irritation to the spine, such as by the actual cautery 
or blisters, will frequently give prompt relief to the paroxysm. 

Hypnotism is a valuable means for the cure of certain classes 
of cases, particularly those with local palsies, either motor or 
sensory. It is of less value in cases involving the entire mus- 
culature. Patients recovering from hysteria should be placed 
in an entirely different surrounding, if the cure is to be permanent. 
The care of the hysterical patient demands a keen insight into 
human nature. It is in this disease that the doctor and nurse, 
through judicious sympathy, alternating with rigidity of disci- 
pline, that the "paralyzed will power'' (for such is not an inapt 
20 




Fig. 



65.— Hysterical Paralysis. Braces and Wheel -Crutch applied to As- 
sist IN Walking till She Gained Powek. — Cured. 



FUNCTIONAL NERVOUS DISEASES 307 

description of the psychological state) greatly assists earlier and 
complete recovery of the patient. It is essential in managing this 
disease to know the history, the heredity of the affection or not, 
and then to learn the predisposing and exciting causes which have 
led up to the " attack," be it a passing syncope, or convulsion, or 
other form of the acute malady. It is these cases where especially, 
as some author has well said, the nurse should have an eagle's eye, 
a lion's heart, and a lady's hand in dealing with the case, one of 
those optimistic Greek maxims which gives vitality to all action. 
In treating any form of hysteria, we will find that 90 per cent of 
the cases cannot be aroused to sudden cures through such agents 
as hypnotism, mental suggestion, and the like; and while such 
measures should be practised in selected cases by the physician 
(with the nurse's aid), still a happy discretion in knowing when to 
abandon these more mysterious methods of cure, successful as they 
are at times, is to be impressed upon us. Therefore, in treating 
hysteria, it should ever be present in mind that these at times 
quicker forms of treatment cannot be continued when we have 
learned that there has been no rapid improvement in the symptoms. 
Local paralysis or spasms of a hysterical nature, are in my experi- 
ence more easily controlled than generalized symptoms, by hypnot- 
ism. ; so that whether it be paralysis, motor or sensory, or of con- 
tractures, the subconscious state is much more difficult to influence 
by this means. In these cases the nurse, who is more constantly in 
attendance than the physician, by lending a spirit of hopefulness in 
pointing out to the patient from day to day improvements observed 
by the physician, will re-enforce therapeutics greatly. And our 
nurses should be better instructed in this fact that, when the lowest 
ebb of will power is established over months and 3"ears in extensive 
chronic paralytic forms of hysteria, nerve energy occasionally is 
never restored; and, therefore, function remains in abeyance with- 
out any pathological lesion taking place other than those accom- 
panying the malnutritional state. The greatest exciting cause of 
hysteria is some form of fright, as is instanced in a case under the 
writer's care, which was awakened by a rat running across the bed, 
since which time she has had hysterical stigmata with generalized 
functional tremor. Another instance is that of a young woman ^ 
who fell down a flight of seven steps without any serious bodily 
harm, although a pain in the back led her to believe that she would 

1 International Medical Magazine, September, 1901. (See Fig. 65.) 



308 TKEATISE ON XEEVOUS DISEASES 

be paralyzed, which .>he finally was. She has now been bedridden 
for three years, with hysterical contractures, anaesthesia of the 
lower limbs up to the knees, and once a clonic hysterical spasm of 
the abdominal muscles; which latter was cured by producing the 
initial stage of ether anesthesia. It took us many months before 
this woman could be impressed enough to show signs giving 
ground for hopeful prognosis, and later cure. I mention these rare 
cases so that the nurses may be taught to understand that nerv- 
ousness is not all foolishness, and has some basis for its existence, 
perhaps, in the theory of immobility of the neurones; and there- 
fore the diverting of the nerve-currents irregularly, which is very 
likely the fact, as suggested by Duval and Lugaro. 

i^erve energy is, to my mind, but the most refined form of 
electricity. There are some physiological phenomena which tend 
to prove this, as in the sense of light-flash perceived when the 
oculist severs the optic nerve in enucleation, or in the sudden res- 
toration of power and sensation following nerve suture, as in a 
case of traumatic operation of the ulnar nerve recently seen by 
the writer. We have in this theory a reason for the efficacy of 
electricity in nervous diseases. 

TRAUMATIC HYSTERIA 

Synonyms: Railway spine; Traumatic hack; Traumatic neurasthenia 

Definition and Causes. — This is a form of hysteria, the result 
of psychic and physical injury. By some it is thought to be a func- 
tional disorder; by other authorities to have an organic basis, the 
milder cases not having, as yet, the pathology fully determined. 
Others describe the condition as entirely mental. Unfortunately, 
this is a disease in which the wildest variation of opinion exists as 
to its nature. We shall give what is accepted by the best authori- 
ties. Traumatic hysteria is more frequent in neuropathic persons, 
is precipitated by some form of physical injury, in contradistinc- 
tion to the idiopathic hysteria, so called, which usually has its 
exciting cause in some psychic trauma alone. Traumatic hysteria 
is more common in the male sex, in whom it is more severe, as a 
rule, than in the female sex. The reason for the more frequent 
occurrence in males is undoubtedly due to the liability to injury 
in men. 

Symptoms and Divisions. — The history of its onset is usually 



FUNCTIONAL NERVOUS DISEASES 309 

as follows : The patient is struck upon the back or thrown from a 
railway carriage, being discovered in a more or less condition of 
shock, with or without consciousness ; and when he is restored the 
phj^sical injury has impressed itself so upon him, that with the 
mental instability induced, the patient imagines that he is seri- 
ously injured, whether this be actually the case or not. On this 
latter depends the dividing course in the symptomatology. If the 
physical injury has been of slight nature the neurotic person will 
develop symptoms entirely psychical. Or, if an injury to the mus- 
cles or ligaments, which in time is healed, occurs, the length of 
time of the actual trouble will be prolonged in such a case by the 
fixed hysteria established during the course of the real trouble. 

The second class of cases develop actual disease of the mem- 
branes and spinal cord of a subacute inflammatory character; or 
it may consist of haemorrhage within the cord, or to irritable weak- 
ness (neurasthenia), and finally to degeneration. 

The first class of cases presents the typical hysterical symptoms, 
plus some local manifestations, the result or supposed result of the 
injury. In the first instance, of course, the actual lesion is soon 
dissipated; in the second subdivision, the history of an accident 
plus these persisting localizing phenomena make plain the organic 
nature of the disease. 

In the purely hysterical cases the patient usually complains of 
rigidity of the back, which upon physical examination is deter- 
mined to exist as the result of tonic spasm of the erector spinae 
groups of muscles. Along the spine there are points of exquisite 
tenderness apt to be localized over cervical, dorsal, and lumbar 
enlargements of the cord. This tenderness upon superficial pres- 
sure is more than upon deep pressure, to which there would be 
exception only in the cases where muscle or tendon injury still pre- 
vailed. In the latter case so-called "tender-spots" will remain 
after the muscle is healed at the site of the original injury. The 
patient becomes irritable, tires at the slightest exertion, mental 
or physical. Palpitation of the heart, bradycardia or tachycardia, 
may exist, and these symptoms frequently are not synchronous with 
the pulse-beat. Per contra, the pulse may be running, feeble, and 
irregular, while the cardiac muscle is not especially disturbed in 
function. This cardio-vascular condition gives evidences of the 
widespread irritability of the sympathetic nervous system, which 
is probably the more affected because of the relation of the gan- 



310 TREATISE ON NEEVOUS DISEASES 

glia to the spinal column, where concussion or a blow upon the 
back would transfer the physical effect immediately to these gan- 
glia lying upon the bodies of the vertebrae. Other vaso-motor 
changes are local or general flushing and sweating or coldness of 
the extremities. Seldom is there a true cyanosis, however. Other 
organs affected largely through the sympathetic nervous system 
are the stomach, producing gastrectasia, borborygmus, hyperacid- 
ity from fermentation of food, and intestines, causing alternating 
serous diarrhoea, abdominal cramp, and physical signs of pseudo- 
appendicitis. The kidney secretion may also be affected, so that 
anuria, polyuria, or even dysuria may occur. Irregularity of the 
sphincter muscle of the bladder may exist, inducing spasm or re- 
laxation with symptoms of tenesmus, incontinence of urine, etc. 

The knee-jerks and other deep reflexes are greatly increased, 
but the valuable point in diagnosis of this first division is that 
true ankle clonus is not present. The muscles are flabby and do 
not show reaction of degeneration nor localized wasting. 

Seldom do sensory symptoms occur other than parsesthesia or 
hyperaesthesia ; anaesthesia, as in simple hysteria, never occurring. 

The psychic symptoms are sometimes bizarre, being entirely 
of hysterical nature, including stigmata and paroxysms of this dis- 
ease in quite exaggerated form. (See Hysteria.) 

The s3anptoms of the second class of cases are again, in the 
majority of instances, largely of psychic nature. In addition there 
are signs of organic disease. 

The milder cases will present the signs of rigidity of the spine, 
already described, plus physical evidences of chronic injury to 
the tissues around, between, or within the spinal vertebrae. The 
points of exquisite tenderness, made worse by the slightest move- 
ment, and perhaps with some superficial swelling, would indicate 
a myositis. Deeper lying points of tenderness, also exaggerated 
by slight movement of the spine, with in some cases undue separa- 
tion of the spinous processes, would indicate relaxation or tear 
of intervertical ligaments or disks, in the latter of which great pain 
would be experienced, when the patient should be assisted to stand 
on his toes and then dropped cautiously upon the heels. These 
patients are never in any degree of comfort, are usually harassed 
by severe pain, though periodic and Avorse at night, preventing 
sleep. Symptoms induced from the persistent insomnia may end 
in a mild grade of mania or even of delusions as to their friends, 



FUNCTIOXAL XERYOUS DISEASES 311 

especially where the doctor and relatives give out that there is no 
organic trouble present. The reflexes are greatly heightened, the 
musculature is frequently in hypertonia, due to irritation, and 
pseudo ankle clonus may exist. In the severer cases in this second 
class the membranes of the cord are congested or in subacute in- 
flammation, which may in time extend to the spinal cord itself, 
producing passive congestion or low-grade myelitis, which can be 
determined by the discovery of persistent ankle clonus, involve- 
ment of the bladder, either incontinence or resultant cystitis, and 
rectal incontinence similar to an ordinary myelitis. A typical case 
of this sort the writer has recently seen where hysteria has been 
pronounced, and yet where, in spite of a large recovery in a suit 
for damages, the patient still has the evidence of organic disease 
referred to. 

Diagnosis. — Simple hysteria is distinguished by the absence pf 
a back injury. Malingering is told by the fact that the malingerer 
cannot consistently simulate the symptoms constantly. 

Progfiosis. — The duration of traumatic hysteria is very indefi- 
nite, the hysterical cases at times being almost as persistent and 
chronic as in organic change of the cord. Where organic lesions 
exist we cannot hope for entire recovery. The pure case of hysteria 
may be well in a few months. That large class of chronic com- 
plainers are incurable hysterics or are the organic cases. 

Prognosis depends entirely upon the skill of diagnosis in distin- 
guishing the different forms mentioned, and in our ability to com- 
mand proper moral and physical treatment of the respective forms. 
It is always most guarded, but it is probable that the patient 
in this disease more than in any other may recover promptly. 

Pathology. — This will vary from nothing (the first division) 
to (in the second class of cases) inflammation of muscles, liga- 
ments, or tendons, or tearing of fibres of the same structures. 
Periostitis, chronic congestion or inflammation of the meninges, 
and the final passive congestion, or degeneration of the neurones 
in the spinal cord, or haemorrhage within the cord may represent 
the pathological findings in the most serious cases. 

Treatment of traumatic Injsteria consists in rest cure for sev- 
eral months in the moderate grade, without organic lesion, or of 
psycho-therapeusis in the most available forms, including hyp- 
notism in these entirely functional cases. The rest treatment is, of 
course, absolutely essential where any organic condition either of 



312 TEEATISE OX XERVOUS DISEASES 

nervous system or surrounding tissue exists. It may be necessary 
in some cases, in addition, to procure fixation of the spine by 
the aid of plaster-jacket or body brace, or by means of head exten- 
sion with the jury-mast. This is to be prolonged until the parts 
have healed or are greatly relieved. Counter-irritation over the 
spine by means of strong tincture of iodine, continued over several 
weeks, the use of blister or of actual cautery may be of great value. 
It must not be forgotten that possibly chipping off of a part of 
a lamina or a vertebral disk may occur, which must be searched 
for by means of X-rays in all cases, and if found, surgical pro- 
cedure should be resorted to. These patients ought never be given 
morphine, else we establish another neurosis, and if drugs are to 
be used, they should be administered sparingly, the indication 
being to quiet the central nervous system, in which the bromides, 
small doses of chloral, hyoseine, and belladonna may be of great 
service. In the functional cases also change of scene is important, 
and in any cases where damage suits are pending they should be 
got rid of at the earliest moment, the physician's duty being simply 
to give advice from a purely medical standpoint, or upon the wit- 
ness stand to state his knowledge of the form and severity of the 
disease from which the patient is then suffering. Much of the dis- 
credit upon the profession will be dissipated when physicians learn 
to give their own opinions after suflicient study in order to know 
what are the underlying conditions in this unfortunate class of 
cases. 

SALTATORY SPASM 

Saltatory spasm is so-called jumpers disease, a hysterical dis- 
order occurring in epidemics in Maine and Canada. It is known as 
miryaclilt in Eussia, and in Java as latali. When the patient 
attempts to stand there are strong contractions of the leg muscles 
which cause a jumping or springing motion. 

SALAAM CONVULSIONS 

This is a hysterical manifestation occurring in certain nation- 
alities, particularly the Malay race. The patient usually is in a 
morbid condition of mind, and without known cause will develop 
peculiar convulsive seizures, from which he is violently thrown to 
the ground in a prone position. This will continue for some min- 
utes, or even hours, the patient finally becoming exhausted and 
passing into a rigid contraction of the general musculature. 



FUNCTIONAL XEKVOUS DISEASES 313 

WRITER'S CRAMP 

Synont3IS : Artisan's palsy ; Ir oner's cramp ; Occupation neurosis 

The above are names given to allied conditions, usually of a 
localized nature, affecting the muscles of a part in spasmodic con- 
tractions, associated with more or less pain along the nerve-trunks, 
and frequently accompanied by wasting of the muscles involved. 
There are several types of the disease, depending upon the physique 
of the person affected and upon the nature of the occupation, as 
above indicated. 

Causes. — The condition is fundamentally a form of nerve ex- 
haustion, and is probably central in the majority of cases, the 
neurones controlling particular movements being exhausted as in 
neurasthenia. The main predisposing cause is heredity as to neu- 
roses, and secondarily, confinement and overwork, such as the 
constant application and overwork of a group of muscles, especially 
when in a constant cramped position. To this primal pathogenesis 
must be added the irritation produced by the variety of metabolites 
formed in excess or improperly eliminated. Leucomaines may be 
complicating factors. Some cases seem to be almost entirely local 
in nature. These are the cases in which the central nervous sys- 
tem is not called upon for a proportional expenditure. 

The more localized types of occupation neuroses may be divided 
into muscular, neuritic (neuritis or not), and arterial, depending 
upon duration and anatomical structures most injured. There are 
no absolutely fast dividing lines between these latter forms. 

Muscular Cases. — This comes on from sudden rather violent 
overuse of muscles, as in cases of brakemen or motormen. A sub- 
acute myositis is very likely set up in these cases. They are usually 
of shorter duration than the other forms, and abate with the 
removal of the cause — i. e., with rest of the affected muscles. 

Neuritic Cases. — Here we have a peripheral neurosis, which 
may pass on to a subacute peripheral neuritis. This class is mani- 
festly more severe than the other forms. Symptoms consist of 
tenderness along nerve-trunks, accompanied by spasm of the mus- 
cles when attempting to use them, especially in the occupation 
"which developed the neurosis. Pressure along the nerve-trunks, as 
is seen in telegraphers, who rest their elbows on the desk, will 
aggravate the condition. A continuing numbness of the affected 
part is another prominent symptom. 



314 TEEATISE ON JSTERVOUS DISEASES 

Vascular Cases. — That these should be given as a type per se 
may be considered dubious from a neurological standpoint, but 
undoubtedly the arterio-capillary involvement is the primogene- 
sis of a number of cases, and the classification seems at least 
to -be warranted clinically. In these cases the ne7'vi vasori and 
vaso-motor nerves are irritated. In such cases there are none of 
the cardinal symptoms of the ordinary cases of writer's cramp, no 
severe spasm or paresis of muscles, but pargesthesia of fingers and 
forearms. Finally, along with delayed sensations of all forms 
(but little tenderness), there is particularly a clamminess of the 
parts so affected. These cases are distinguished from acroparses- 
thesia by the fact that there is evident pressure cause for the 
peripheral irritation and from the fact that marked arterial scle- 
rosis is found wanting. The arterial cases may also be divided 
into the neurasthenic and non-neurasthenic. 

The muscular class of cases are the more frequent, and from 
the fact that the muscles are more affected; and in which treat- 
ment is the more prompt in producing results. The prognosis, 
therefore, is much better in this class of artisan^s palsy. 

The neuritic class are the usual cases described in classical arti- 
cles on the subject, and are the most persistent ones, in which there 
is almost constantly a background of neurasthenia complicating. 
Such patients are usually emaciated and suffer from insomnia and 
anorexia. Morris Lewis has best described this disease.^ 

Prognosis. — In the vascular cases this is good in the absence of 
neurasthenia ; and the patient will recover, as a rule, with the gen- 
eral upbuilding of health after the occupation has been abandoned. 
In a study of some 50 cases of artisan's palsy, at the Infirmary 
for Nervous Diseases, occurring over some twenty-five years, the 
writer made a study of the Eemote Eesults of Artisan's Palsy ^ 
with the following conclusions: That with the proper kind of 
treatment, and if persisted in, these cases offer a better recovery 
than was formerly supposed. Two to five years seems to be a 
fair time for cure in the average case of neuritic type. Where 
the central nervous system is involved we have the terminal stage 
of irritation (neurasthenia), most unpromising for complete cure. 
Muscular types offer the most favourable prospect for ameliora- 

1 The Neurologic Disorders of Writers and Artisans, Pepper's System of 
Medicine, vol. v, pp. 50^542. 

2 University of Penna. Medical Magazine, May, 1897. 



FUNCTIONAL NERVOUS DISEASES 315 

tion; here no remote conditions need be entertained, and stop- 
ping the progress of the disease will generally produce rapid 
recovery. The hybrid cases I have designated arterial type are 
also very persisting. In proportion as arterial sclerosis is absent 
and external irritation is prominent will the hope for complete 
recovery be gratified within six months to a year under the proper 
kind of treatment. Where the disease lasts beyond a year, the 
remote effects are arterial sclerosis, probably induced by the vaso- 
motor irritation of such long duration; then the deposit of lime 
salts will of course continue with some remissions, as is the his- 
tory of this form of arterial degeneration. 

Treatment. — The use of antirheumatics, such as potassium' 
iodide, the lithic salts, and sodium salicylate, are of great advan- 
tage in those cases where rheumatic diatheses prevail. The use 
of nitroglycerin or ergot will be of value in the arterial cases with 
constriction or relaxation respectively through action upon the 
vaso-motor nerves. Nutrient drugs such as cod-liver oil and 
the hypophosphites will be of help in cases associated with mal- 
nutrition. Fresh air and sunlight should be insisted upon in all 
cases, also relaxation from overwork. We should employ haematics, 
such as Blaud^s pills, in cases of anaemia. Since the psychology of 
the disease is to produce a peculiar morbid depression, it is impor- 
tant for the physician to gain the confidence of the patient and 
stimulate him to the thorough realization of the need of careful 
treatment. The local measures of value, which should be contin- 
ued for many months, are massage, galvanism, and hot local bath- 
ing to the part from three to five minutes daily, in cases where 
there is considerable pain or spasm. In some cases a splint should 
be applied to the affected m^ember in order to afford relief of 
spasm by enforced rest. Treatment of existent neurasthenia is 
absolutely essential for success. 



CHAPTEE XVII 



VASO-MOTOR AND TROPHIC DISORDERS 

Synonyms: Parry's disease (1825); Graves's disease (1835); Basedow's 
disease (1840), etc, 

EXOPHTHALMIC GOITRE 

This is a disease characterized by rapid heart, exophthalmos, 
enlargement of the thyreoid gland, and by disturbance of the 
vascular system through functional disease of the ^sympathetic 

nervons system. 

Causes. — There are vari- 
ioiis theories for this affection. 
That it is a functional disease 
of the sympathetic nervons 
system is held by most author- 
ities. Exciting causes are 
overwork, fright, auto-intoxi- 
cation, or infection. It is 
closely allied to simple goitre, 
or at least hybrid cases fre- 
quently are found. "WHiether 
or not disturbance of the thyr- 
eoid function has primarily 
to do with Graves's disease is 
still debatable. 

Those contending for this 

consider that there is an 

excess of secretion (hyper- 

thyrea), as against the lack 

of that secretion as a cause of 

the development of myxoe- 

dema (athyrea). The age of 

onset is usually between the twentieth and thirtieth years, and it 

is sometimes seen in several of a family. Some observers consider 

that the affection is due to a lesion in the oblongata. 

316 




Fig. 



66.— Exophthalmic GoItke. Prom- 
inent Eyes and Thyreoid Gland. 
(Howard Hospital.) 



VASO-MOTOR AXD TROPTTIC DISORDERS 317 

Symptoms. — There are two types of this disease, Damely, the 
acute and "the chronic. The former type may develop with great 
rapidity, following an attack of vomiting and diarrhoea, tachy- 
cardia, and throbbing of the arteries. Such cases may die in the 
attack as early as the third day of the aifection. Marked cerebral 
symptoms may be present in this form. More frequently the grad- 
ual onset prevails, the three cardinal symptoms varying in order of 
onset. The cardiac and vascular symptoms are usually first to 
develop, the patient complaining of palpitation and dyspnoea. The 
pulse is found to be increased in force, the apex beat is in the nor- 
mal position, and the carotids and abdominal vessels may be throb- 
bing visibly. Occasionally capillary and venous pulsation may be 
seen in the hands. At its height the pulse rate may be from 140 
to 160, or even more in some cases. It seldom drops below 95 
per minute. Emotion tends to increase the heart action, and on 
exposure of the skin on the chest a transient hypersemia quite fre- 
quently can be seen. Basic murmurs are not unusual. Long- 
standing cases may present cardiac hypertrophy. The heart 
sounds become greatly accentuated, some cases having been record- 
ed where the heart-beat could be heard several feet away from the 
patient. Usually exophthalmos follows next, and is readily recog- 
nised by protrusion of the eyeballs, and also by the lids not com- 
pletely covering the sclerotic coat. The protrusion may sometimes 
cause semi-dislocation of the eyeballs. Vision usually remains in 
a normal state. Yon Graefe's sign, consisting of the inability of 
the particular lid to follow the downward movement of the eye- 
ball, though striking, is not a frequent symptom. Stellwag's 
sign consists in a greater width of the palpebral aperture than in 
health owing to the retraction of the lid, this usually being found. 
The patient winks infrequently. Occasionally there is lack of 
convergence of both eyes. The optic nerves are seldom affected, 
but pulsation of the retinal arteries is common. The thyreoid 
swelling usually appears with the exophthalmos. It is generally 
symmetrical, but seldom as large as in ordinary goitre. The blood- 
vessels are much dilated, and the gland is occasionally seen to 
pulsate ; in either instance a thrill may be felt, or on auscultation 
we discover a bruit or even a loud systolic murmur. Motor symp- 
toms consist of fine general tremors. The patient becomes anaemic 
and emaciated. He may be slightly feverish at times. Vomiting 
or diarrhoea may exist and are usually paroxysmal in occurrence. 



318 TREATISE OX XERVOUS DISEASES 

Great complaint generally ir^ made of throbbing sensations in 
the head, accompanied by a sense of flushing and heat with profuse 
perspiration. The skin will be found, when carefully examined, 
to be pigmented, favouring Addison's disease ; or patches of leuco- 
derma, or atrophy of pigment and urticaria may exist, as may 
also areas of solid oedema. Myxoedema has been found to coexist 
with this affection. The patient is also of irritable temperament 
and of changeful disposition, mental depression very frequently 
occurring. Acute mania may develop. A sense of giving way of 
the legs,, a muscular weakness, may exist. There is great diminu- 
tion in the electrical resistance, which may be due to moisture of 
the skin from vaso-motor dilatation. Bryson has noticed that the 
chest expansion is greatly diminished. Breathing is hurried and 
shallow. Albuminuria and glycosuria are not usual symptoms 
found present upon frequently examining the urine. Polyuria, 
hyperidrosis, and oedema are usual. Subnormal temperature 
might occur. 

Prognosis. — This disease usually lasts for many years, but after 
six months' time it may disappear. Complete recovery is, as a rule, 
very rare. Instances are recorded of the acute form recovering 
within the same period of time as its development — a few days. 

Patliology. — This is inconstant. The heart is often dilated. 
Fatty change of its walls may be present. The lobes of the 
thyreoid are large, firm, and pulpy. Colloid degeneration and cyst 
formation may be found. The vessels are thickened and athe- 
romatous. There is proliferation of connective tissue through- 
out the gland. In the bulb and cord haemorrhages have been 
found. 

Treatment. — This consists in rest, the absence of worry, 
abundance of sunlight and oxygen ; the use of galvanism, placing 
the positive pole over the apex of the heart and a Y-shaped divi- 
sion of the negative pole upon each side of the neck over the cervi- 
cal sympathetic, with from 3 to 10 milliamperes, once or twice 
weekly, has proved of value in our hands to lessen the rapidity 
of the heart. The use of strophanthus in continuous dosage is of 
advantage for the cardiac irritability; where there is great vaso- 
motor disturbance prominent, the use of digitalis or its products, 
especially digitaline (| grain t. i. d.), will prove of value. The 
alterative and haBmatinic effect of arsenic, especially when com- 
bined with iron, will prove a boon in anaemic cases. Ergot is 



VASO-MOTOR AXD TROPHTO DISORDETIS 319 

recomnieiided by some writers. Tincture of beiladoniui will very 
frequently give relief, and should be pushed to the physiological 
limit. Resort to the rest-cure may be a necessity in the worst of 
cases. The application of Leiter's tube, or an ice-bag over the 
heart or lower part of the neck, frequently gives relief. Organo- 
therapy has not been successful in the majority of cases. Surgical 
treatment cannot be recommended, although several recoveries 
have already been reported after excision of the cervical sympa- 
thetic or part of the gland itself. 



GLASS-BLOWER'S DISEASE 

This is a vaso-motor neurosis, due primarily to sudden increase 
of blood pressure and the forcing into the blood an excess of 
oxygen caused by the patient blowing into the blow-pipe, fol- 
lowed by a deep inspiration when the mouth is removed, at which 
time the blood becomes overaerated ; the latter being the real cause 
of the cardinal symptoms of the disease. The former is productive 
of emphysema of the lungs, which, therefore, is a common com- 
plication. Dizziness is a marked symptom, and is an exaggeration 
of what can be produced by respirations deeply and rapidly taken 
during health. In these patients there is a beginning hypertrophy 
of the right ventricle, accentuation of the second aortic sound, 
and an increased pulse volume and rate. There soon results ex- 
haustion, d3'spnoea, and a rapid running pulse, the patient com- 
plaining of fulness of the head, and while exhilarated is unable 
to co-ordinate properly. This is due to overstimulation of the 
central nervous system. Mental anxiety is pronounced. 

Pathology. — This is, as indicated, overoxygenation of the hlood 
primarily, with sequent hypertrophy of the heart and vascular dis- 
ease in chronic cases. 

Prognosis. — When once firmly established the prognosis is ab- 
solutely bad if the patient continues the occupation. These cases 
very seldom live after fifty-five years if they continue work at the 
same trade. If the occupation is stopped, it may be that the 
patient may live quietly in comparative comfort for some years. 

Treatment. — The patient should quit glass-blowing. Employ 
antispasmodics, such as lobelia, where the emphysematous symp- 
toms are predominant; nitroglycerin to steady the circulation 
and overcome dilatation of the peripheral vessels. It must be re- 



320 TEEATISE OX NERVOUS DISEASES 

membered that there is a possibility of cerebral haemorrhage in 
cases with arterial sclerosis. Here the treatment is directed to apo- 
plexy. These complicated cases are generally fatal. 

SUDDEN CHANGES IN HAIR 

This rare trophic condition occurs, as a rule, as the result of 
grave mental crises in life or extreme fright. 

Symptoms.— The patient after severe psychic shock, as indi- 
cated, may notice within a few hours to several days a sudden gray- 
ing of the hair in streaks or in entirety in a given area ; usually of 
the scalp and eyebrows. In some cases an alopecia will precede, 
accompanied by erythema or with distinct dermatitis in the area 




Fig. 67. — Tkophoneurosis op the Hair, showing Change from Dark to 
White. (Author's reported case.) ^ 

affected; and when the hair returns the absence of colour will be 
noted. The hair, as a rule, remains without colour (gray or 
white), and may be disposed to fall out from time to time, depend- 
ing upon the mental condition of the patient as well as the nutri- 
tion of the body. The hair change may result in universal and 
permanent alopecia alone (Fig. 68). 

Causes. — The writer has records of two cases produced by 
shock, one in a male, communicated personally by Dr. E. Pearce, 
of Ohio. Here the hair turned permanently gray in one night, the 
man having been frightened during the civil war by rapidly fired 

> American Medicine, Dec. 28, 1901. 



VASO-MOTOR AXD TROPHIC DISORDERS 321 



cannon. Another case un- 
der our care is of a young 
woman, following a dis- 
appointment in love, the 
hair having dropped out 
and then shortly regrew, 
being perfectly white (Fig. 
67). Psychic trauma is 
the cause. 

Pathology. — This is in 
an indefinite state, consist- 
ing in the absence of de- 
posits of colour matter, 
which must be dependent 
upon some trophic disturb- 
ance of the nervous sys- 
tem similar to other dys- 
trophies. Metchnikoff has 
described the amoeboid ac- 
tion of certain leucocytes 
which he designates pig- 
mentophytes. 

Prognosis. — This is 
good so far as the health 
of the patient is con- 
cerned. The hair seldom 
returns to its normal col- 
our again. 

Treatment. — Rest and 
tonics are essential. Drugs 
to stimulate the sweat- 
glands and to favour the 
deposits of normal colour- 
ing matter would be indi- 
cated, such as pilocarpine 
and iron. The static 
breeze as a ' stimulant to 
the surface of the skin is 
indicated. The use of 
phosphorus and strych- 
21 




Fig. 68.— Universal Alopecia of Nervous 
Origin. (Philadelphia Hospital.) 



322 



TREATISE ON NERVOUS DISEASES 



nine ; or the nuclein bodies^ or organo-therapy^ as thyreoid extract, 
may prove of service in the treatment of this uncommon affection. 

HYPEROSTOSIS CRANII (CEPHALOMEGALY) 

This disease is allied to osteitis deformans, originally described 
by Sir Janies Paget, of London, in a report of the first case, 
November 24, 1876. When the disease is limited to the cranial 




Fig. 69. — Hyperostosis Cranii. (Author's reported case.) ^ 

bones largely, as in the case shown in the two photographs, it is, as 
already designated, hyperostosis cranii ; and becomes a neurological 
affection only in its relation by contiguity of the enlarged bones 
to the brain mass. 

This affection is a trophic disturbance, involving the bones of 
the skull, the rest of the bones of the skeleton being but little 

* Transactions of the Pathological Society of Philadelphia, vol. xviii, 1897. 



YASO-MOTOR AXD TROPHIC DISORDERS 323 

or not at all involved. There are two types ^ of cranial enlarge- 
ments : 

(a) Upper-head type. 

(h) Lower-head type, where the malar bones become involved 
and produce the Iconic appearance. The face and head present an 
oval with the base up. The bony overgrowth may begin as early 




Fig, 70.— Skull-cap from same case of Hyperostosis Craxii. (See Fig. 69.) 



as the twelfth year, and usually it is not later in onset than the 
twentieth year. The condition is undoubtedly a bony dystrophy. 
Symptoms. — The symptoms of this disease are very indefinite. 
There is usually mental apathy, a state of mental hebetude, and 
occasionally a condition of what we might call "queer/' The 

* J: J. Putnam, Trans. Am. Neurological Society, June, 1895. 



324 TREATISE OX XERVOUS DISEASES 

patient may also suffer from a dull headache. The bony enlarge- 
ment is gradual, the hearing becomes affected in some cases, and 
the hairs are noticed to become coarse, and even may fall out to 
some extent. The case may die of asthenia after many years, or 
he may be carried off by some intercurrent malady, such as pneu- 
monia, or chronic interstitial nephritis. 

Patliologij. — This consists of a slow ostitis. The chronic in- 
flammation shows under the microscope irregularly enlarged Ha- 
versian systems, atrophy of bone cells, loss of osteophytes and 
osteoclasts, and the conversion of parts of bone into mere fibrous 
tissue. On the surface of the bone there is, as a rule, a condensing 
ostitis. There is frequently cerebral arterial sclerosis in marked 
degree. 

Diagnosis. — This lies between the disease in question and 
spurious forms of hydrocephalus; but the lack of exophthalmos 
after prolonged cephalic enlargement with other signs of bone 
thickness would militate against the latter. The case reported by 
the writer (Figs. 69 and 70) occurred in a woman seventy- two 
years of age. Here the skull-cap proved to be 1^ inch in thickness, 
and as far as I can determine is probably the thickest on record. 

Treatment. — The treatment of this condition is, of course, 
in cognito. Xutritional measures and probable benefit from 
organo-therapy should be thought of. Antisyphilitic drugs should 
be tried in all cases. 

ADIPOSIS DOLOROSA 

This is described by Dercum as a disease of adults in which 
there is a deposition of fat in various parts of the body seen in 
the form of bunches or nodules, becoming uncircumscribed after- . 
ward, and accompanied by pain, diminished sensibility, and great 
muscular weakness. There is the sensation as of a bunch of worms 
transmitted to the hand on palpation. Some 15 or more cases have 
been reported by Dercum, Henry Ewald, Peterson, Loveland, 
Spliler, Eshner et ah 

Diagnosis. — This condition must not be confused with myx- 
cedema, since in the former changes do not occur in the hands and 
feet, and there is an absence of mental symptoms. Ordinary adi- 
posis also affects the hands and feet. It is not painful. 

Pathology. — This consists in deposition of fat as described, 



VASO-MOTOll AND TEOPHIC DISORDEES 325 

in all probability due to a central trophic disturbance. Degenera- 
tion of the ultimate nerve filaments has been found by Burr and 
McCarthy, of Philadelphia. 

Prognosis. — This condition may last for many years, the 
patient dying of asthenia or fatty degeneration of the heart. 




Fig. 



n. — Adiposis Dolorosa in a Colored Woman. 
Hospital. ) 



(Medico-Chirurgical 



Treatment. — Hygienic measures are to be employed; living in 
the open air, the use of thyreoid gland extract, and massage may 
all prove of value by aiding catabolism. 



326 TKEATISE ON NERVOUS DISEASES 

FACIAL HEMIHYPERTROPHY 

This is a condition of overgrowth of the soft tissues and bones 
of one side of the face, being the exact opposite to that of facial 
hemiatrophy. Care must be observed not to confuse this affec- 
tion with facial hemiatrophy, in which the normal side would be 
mistaken for the atrophied side of facial hemiatrophy (see below). 

Pathology. — It is supposed to be a trophic disturbance of the 
central nervous system. The tissues are hypertrophied. 

FACIAL HEMIATROPHY 

Is a disease characterized by progressive wasting of the tissues, 
particularly of the bones on one side of the face ; starting in child- 
hood, but in some instances at middle fife. It usually begins dif- 
fusely, but in some cases at a single point on the skin and grad- 
ually spreads, involving at first the subcutaneous tissues, then 
the muscles and bones, and particularly the upper jaw. The 
atrophy is sharply limited at the middle line, the face looking 
as though it was made up of two halves from different persons. 
The colour of the skin changes and the teeth fall out, due to the 
wasting of the alveolar processes. Even the orbit is seen to become 
atrophied on the affected side, and the e3^eball may become 
shrunken. There are instances on record in which the disease was 
bilateral, and in a few cases where the atrophy extended to the 
back and arm of the same side, the face was also affected. It is a 
rare affection, only 97 cases being gathered from literature by 
Sachs, of New York. 

Pathology. — In one of the few autopsies made by Mendel he 
determined the terminal stage of interstitial neuritis in all the 
branches of the trifacial nerve from their origin to the periphery, 
more severe in the superior maxillary division. In a case reported 
by Homen a tumour was found pressing on the Oasserian ganglion. 

Diagnosis. — This is not difficult, since the appearance is most 
striking. Facial asymmetry associated with wry-neck, which, devel- 
oped in the early childhood, is the only disease with which it may 
be confounded. The torticollis would make plain. 

Treatment. — There is no treatment known at the present time 
that has a curative tendency in this affection. The hygienic care 
of the patient should be very strictly pursued as well as supportive 



VASO-MOTOR AND TROPHIC DISORDERS 327 

measures, and no doubt the progress of the disease can be pre- 
vented to some extent in a few instances. 

DERMATITIS GANGRENOSA NERVOSA 

Gangrenous dermatitis of nervous origin is a trophic affec- 
tion, coming on suddenly and periodically. In individuals of neu- 
rotic stock it is most commonly seen, and sometimes it is present 




Fig. 72.— Dermatitis Gangrenosa Nervosa, showing Scars on Dorsum of 
Left Hand of Young Woman, the Result of this Disease. 

in patients that are of good health otherwise. The attacks of 
superficial gangrene in this rare disease the record of the follow- 
ing case will well demonstrate: 

A. B., aged twenty-six, white, hysterical, but of good 



328 



TEEATISE OX NERVOUS DISEASES 



physique, no organic disease existing at any time. During one 
night she may develop patches of irregular serpiginous dry gan- 
grene of the superficial la3'er of the derma upon the hands and 
trunk. This change is most striking, and may occur during a 
single night. The sphacelus sloughs off, leaving chronic ulcera- 
tion, which heals slowly under antiseptic treatment within a few 
weeks. There is no constitutional disturbance at any time. 

Path genesis. — These cases are very difficult to explain, but 
they must depend upon some transient trophic functional disturb- 
ance of the central neuron, with probably an auto-intoxication; 
the fundamental cause being instability of the central nervous 
system. 

Prognosis. — The patient may live for many years suffering 
from recurrent attacks, and finally recover altogether. 

Treatment. — This is largely prophylactic in that of upbuild- 
ing the nervous system (perhaps by rest-cure). Change of scene, 

outdoor life, and hypernu- 
trition may avail towards 
preventing attacks. 

MYXCEDEMA 

This is a disease char- 
acterized bymyxoedematous 
degeneration of the subcu- 
taneous tissues in youth 
or adult life. It occurs 
more frequently in males. 
The affection is due to dis- 
ease of the thyreoid gland 
in which there is defect of 
internal secretion of this 
organ. When the disease 
begins in early life the 
name sporadic cretinism is 
applied ; and when it oc- 
curs as the result of extir- 
pation of the thyreoid 
gland it is designated cachexia stnunipriva. Myxoedema occurs 
more frequently from about the thirtieth up to the fortieth year of 




Fig 



73. — Sporadic Cretinism. 
Hospital.) 



(Philadelphia 



VASO-MOTOR AND TROPHIC DISORDERS 329 

age. It may follow erysipelas, rheumatism, persistent haemor- 
rhages, or syphilis. 

Symptoms are of mental obtundity with the physical sign of 
enlargement of the body through a universal deposit of myx- 
oedematous degenerative material in the subcutaneous tissues. The 
patient seems fleshy, but the skin is harsh, dry, and sallow-looking 
rather than normal in colour. There is no true oedema. The ex- 
pression becomes blank, the patient complains of great feeble- 
ness, the lips and lobules of the ear and eyelids thicken. The intes- 
tinal tract is torpid, the secretion of the kidneys is but little. This 
condition exists for some years without much change from month 
to month. The face is round, in contradistinction to the face in 
Paget's disease or in acromegaly. The hands are clubbed and 
puffy, not " spade-like," as in acromegaly. 

Prognosis is good as, to improvement, wonderful results being 
obtained by means of the use of the thyreoid gland internally, this 
making up for the deficiency in the diseased body. 

Treatment. — The extract of the thyreoid gland may be given in 
grain doses, three times a day, gradually increased until palpita- 
tion of the heart may be produced. This must be kept up from time 
to time as the appearance and weight of the case will indicate. 

SCLERODERMA 

Is a condition of diffused or localized induration of the skin. 
There are two types : the circumscribed, which corresponds to the 
keloids of Addison or to morphcea; and the diffuse, in which 
large areas are affected. This disease affects females more fre- 
quently than males, and occurs in early middle life, although it 
is seen in spurious form in babyhood — the so-called sclerema 
neonatorum. — by some said to be a different affection. This latter 
disease has occurred only in the French and German races so far 
as reported. It may at times be of specific origin. 

(1) The form mostly seen in this country is the circumscribed 
type. The patches range from a few centimetres in diameter to the 
size of the hand or larger, are waxy in appearance, and to the touch 
hard, brawny, and inelastic. There may be a precedent hypersemia. 
Following these manifestations pigmentary changes of the skin 
occur either of excess or absence — leueoderma. The sensory dis- 
turbances are rare. Perspiration is diminished or absent. This 



330 TEEATISE ON ISTEEVOUS DISEASES 

type is much more common in women than in men, and is situated 
about the neck and sometimes along the courses of the nerves. 
Patches may develop with great rapidity, and may last but a few 
days or persist for years. 

(2) The diffuse form, though less frequent, is more serious. It 
appears in the face or in the extremities. The patient notices 
that the skin is unusually hard or firm, and there is a sense of tense- 
ness in making accustomed movements. Gradually a brawny, in- " 
duration develops, the skin' becomes united to the subcutaneous 
tissues, and it cannot be picked up or pinched. The skin may look 
natural, but more commonly is glossy, dry, and unusually smooth. 
This form is apt to affect, in order, the upper extremities, the 
trunk, the head or face, the upper portions of the lower extremities, 
and least frequently may become universal. Occasionally sensory 
disturbances are found, the disease may last many years and recov- 
ery may occur, or rarely it may be arrested. Eheumatism and endo- 
carditis may complicate, or it may be associated with Reynaud's 
disease as reported by Mackenzie. The patient may be carried off 
by pulmonary or renal disease. 

Pathology of the disease is unknown, probably a tropho-neu- 
rosis dependent upon changes in the arterioles of the skin, leading 
to connective-tissue overgrowth. 

Sclerodactylie is the same disease manifested by symmetrical 
involvement of the fingers, which become shortened, deformed, and 
atrophied. Ulcerations have been met with, also great deformity 
of the nails. This disease is occasionally associated with sclero- 
derma proper. 

Treatment consists in mixed -luetic medication and in thyroid 
therapy. 

AINHUM 

This is a rare condition occurring in the negroes of Brazil, 
India, Africa, and occasionally in the Southern States. It is con- 
fined to the toes, usually the little toe. It commences as a furrow 
on the line of the digito-plantar fold, which gradually deepens, 
the under side of the toe enlarges, usually without inflammation 
or pain, and the toe drops off. The condition may last for years, 
however, before spontaneous amputation follows. Treatment has 
proven futile in all cases. Antisepsis would be indicated. 



VASO-MOTOR AXD TROPHIC DISORDERS 331 



ACROMEGALY 

This is a distrophy characterized by abnormal enlargement 
chiefly in the bones of the face and extremities. The word was in- 
troduced by Marie/ and means large extremities. The disease 
occurs as frequently in both sexes and usually begins about the 
twenty-fifth year, although it has occurred much later. Syphilis, 
rheumatism, and the specific diseases have preceded the develop- 
ment of this malady, but probably have no special connection with 
it. Disease of the pituitary body is said to be causative. 

Symptoms. — In a well-marked case the signs are characteris- 
tic. The hands and feet are greatly enlarged; fingers are sau- 
sage-shaped. The joints are freely mobile. The hypertrophy is 
general and gives a spade-like character to the hands. The wrists 
are frequently enlarged, the arms rarely affected. The nails are 
broad and large. The lips and tongue are enlarged. The head 
is increased in volume (oval, with base down) ; the face more so 
in proportion, ^hich latter becomes elongated and enlarged in 
consequence of the increase in size of the superior and inferior 
maxillary bones. This was especially noticeable in a case coming 
under the writer's care, which was also accompanied by bitemporal 
hemianopsia and mental stupor. The lower jaw in particular 
enlarges and frequently protrudes beyond the upper. The alveolar 
processes are widened and the teeth separated. The eyelids are at 
times thickened, the ears greatly enlarged. At times the tongue 
becomes hypertrophied, and later in the affection kyphosis may 
develop and the bones of the thorax may slowly enlarge. With it 
all the skin may seem quite normal, but occasionally may become 
coarse and flabby, never having the dry, harsh appearance of the 
skin of myxoedema. The patient is depressed in spirits and phys- 
ically weak. There may be hyperidrosis, loss of sexual power, fron- 
tal headache; or bitemporal hemianopsia due to ventral pressure 
of the enlarged pituitary body upon the optic chiasm. 

Pathology. — In addition to hypertrophy of the bones great 
cystic enlargement of the hypophysis (pituitary body) has been 
found. The disease is no doubt a nutritional disturbance analo- 
gous to myxoedema, and is probably due to disturbance of function 
of the pituitary body. Organic change in nerve tissue is absent. 

Diagnosis. — The congenital progressive h}^ertrophy of trunk, 

1 Revile de Med., 1886. 




Fig. 7-i.— Acromegaly in a Woman, showing Enlarged Supra-Orbital Ridges, 
Inferior Maxilla and Hands. (Medico-Chirurgical Hospital.) 



VASO-MOTOR AXD TROPHIC DISORDERS 333 

jirnis, or legs — the so-called giant growth — is easily recognised. In 
this there are never eye symptoms. 

In the osteitis deformans of Paget the shafts of the long bones 
are involved; and in the head the bones of the cranium, but not of 
the face, as Marie states. In Paget's disease the face is triangu- 
lar, with the base up ; in acromegaly it is ovoid or egg-shaped, with 
the large pole down; while in myxoedema it is round. In hyper- 
trophic pulmonary osteo-arthropathy, while enlargement of the 
hands and feet occur it is chiefly in the lower three-fourths of 
the forearm and legs, but there is not any involvement of the 
face. (See below.) 

Prognosis is bad as to cure. Sometimes the patient can be 
bettered by general hygienic regime. Thyreoid extract and pitu- 
itary body have been recommended, and much good has resulted 
from their use. Alteratives, hot baths, rest, and sunshine may tend 
to stay the process. 

The liability to sudden death must be remembered, as in the 
instance of a typical case under the writer's observation. The man 
apparently died of heart failure of reflex origin, he having fallen 
over while at work, and when in average physical health. Iso 
autopsy was permitted. 

HYPERTROPHIC PULMONARY OSTEO- 
ARTHROPATHY 

Marie has given the name hypertrophic pulmonary osteo- 
arthropathy to a queer disorder characterized by enlargement of 
the hands, feet, and of the ends of the long bones, chiefly of the 
lower three-quarters of the forearms and legs. The bones of tho 
skull and face are not involved. The terminal phalanges are much 
spread with both transverse and longitudinal curves. The nails 
are also enlarged and much curved over the ends of the phalanges. 
Scoliosis and kyphosis have both been met with. It is a chronic 
disease, and in nearly all instances has been associated with some 
long-standing affection of the bronchi, lungs, or pleura — hence its 
name — of which sarcoma, chronic bronchitis, and pulmonary tu- 
berculosis have been the most frequent. It may develop in those 
who have had syphilis. It is more common in adult males. 
Thornburn ^ has collected some 30 cases of this rare disease and 

1 British Medical Journal, vol. i, 1893. 



334 TREATISE OX XERVOUS DISEASES 

others have beeu reported since. We have seen 3 cases. Dull 
pain in the extremities was a symptom in each patient. 

Pathology. — This is very obscure. Marie suggests that the 
toxins of the pulmonary disease are absorbed and irritate bony 
and articular structures. Thornburn believes it is a benign 
chronic tubercnlous affection. The nervous system may be at the 
bottom of the disease ; it is very probably a trophoneurosis. 

Treatment shonld consist in combating the pulmonary disease. 
The use of cod-liver oil^ hypophosphites, and nutrients may thus 
be of service. Protection of the parts from cold is essential. 
Ichthyol ointment (1 dram to -J ounce) may have some soothing 
influence through its sorbefacient effect. Antisyphilitic treatment 
should be carried out faithfully. 

ARTHRITIS DEFORMANS (Rheumatoid Arthritis) 

Etiology. — Dr. John K. Mitchell, Sr., contended that this was 
a trophic nervous disease as long ago as 1827. There seems no 
better place to classify this disease. It is a trophic affection in- 
volving the smaller joints of the hands and feet; occasionally 
the larger joints. It is characterized by changes in the cartilages 
and synovial membranes, with periarticular formation of bone and 
great deformity (see Figs. 75, 76, and 77). The association of the 
disease with shock, worry, or grief will support the theory of its 
nervous origin; also its similarity to arthropathies, as of tabes. 
The symmetrical distribution of the lesions, the skin and nail 
changes, and muscular wasting out of proportion to the joint mis- 
chief point towards a trophoneurosis. 

Ord regards the disease as similar to progressive muscular 
atrophy due to primary changes in the cord; or to peripheral irri- 
tation, as of trauma or uterine disease, these causing secondary 
changes in the cord. Females are much more liable to the disease 
than males. In Garrod's table of 500 cases it occurs in females 
411, and in males 89 times. Exhausting disease, such as prolonged 
sepsis or typhoid, may precipitate it. 

Symptomatology. — The disease may begin in children (six to 
twelve years), in old age but rarely. It usually originates between 
twenty and thirty years of age. Hereditary influence favours 
early development. It has no more predilection for the poor than 
the rich, and I have seen it in the most lowly as well as in the 



A^ASO-MOTOR AXD TROnilC DISORDERS 335 

best stock in America ; though in Enghmd and on the Continent 
the poor, from given statistics, suffer most. There are three 
forms of the disease: (1) The general progressive form; (2) the 
partial monarticular form; and (3) that in which Heberdeen's 
nodosities are prominent. In the latter form " little hard knobs " 




Fig. 75. — Agglutination, Patella to Tibia and Subluxation of Knee, in 
Rheumatoid Arthritis. X-ray photograph (kindness of Dr. R. P. Cummins, 
Howard Hospital). 

develop gradually at the sides of the distal phalanges. These oecui 
later in life in the average case (thirty to- forty years or over). 
Such subjects may have had digestive troubles. The joints may at 
first be swollen or red, especially when injured. The dorsal sur- 
face of the second phalanx increases in size, giving the character- 
istic appearance of the joint. Charcot contended that urate of 
soda is never deposited. These patients seldom have involve- 



VASO-MOTOR AND 'rROPIIK" DISORDERS 33? 

ment of larger joints, although exceptions do occur. (See Figs. 
75 and 77.) 

Of the progressive form there are two types, acute and 
chronic. Many joints may be involved at first in swelling, red- 
ness, distention of synovial sheaths and bursse. It is more com- 
mon in women between twenty and thirty and after prolonged 
lactation or rapid childbearing. Eemissions may occur. The 
chronic form is the most frequent. Pain on movement and slight 
swellings due to effusion into joints and the periarticular sheaths 
are the first symptoms. Pain is, however, an extremely variable 
symptom. Gradually the shape of the joints is greatly altered, 
partly by the great thickening of the ligaments, and still more by 
retraction and atrophy of the muscles. 

Crepitation can be felt on movement due to eburnation of the 
articular surfaces. The joints finally become completely locked, 
not by true ankylosis, but by the osteophites, which, as Osier de- 
scribes, are like the ring bones in horses. Spurious ankylosis may 
occur also from thickening of the capsular ligaments and by 
fibrous adhesions. Contractures and contractions occur and bring 
about most marked flexion of legs upon the thighs and the thigh 
upon the abdomen. In other cases the muscular wasting is so 
rapid that central disease will again alone explain their pathology. 
Fortunately in some cases the fingers and toes are not so much 
involved, and the patient is able to knit, etc. Numbness, tingling, 
pigmentation, and glossiness of the skin exist. In the worst cases 
all the joints of the extremities become locked and the patient lies 
curled up in led helpless. Conservatism of nature and compensa- 
tory function are beautifully demonstrated in some of these pro- 
nounced cases, however; the patients frequently accomplishing 
under great difficulties many artistic designs where the talent 
exists. 

The partial or monarticular forms are found mostly in the 
aged, and are particularly seen in the knee, hip, shoulder, or spinal 
column (spondylitis deformans). (See Ehizomyelique Spondyl- 
itis.) If in the hip, the term morbus coxoe senilis is applied to 
the affection. Injury frequently precipitates cases involving one 
joint. This form occurs particularly in men. We have one such 
case. 

Diagnosis. — Arthritis deformans should not be confused with 
rheumatism or gout. The monarticular form of simple local 
22 




Fig. 



77. — Rheumatoid Arthkitis with Co>!TKACTURes. Bedridden 
girl before operation. (Howard Hospital.) (See Fig. 78.) 




Fig. 78. — Rheumatoid Arthritis, after Operation and Braces 
ARE Applied. (Howard Hospital.) (See Fig. 77.) 



340 TREATISE OX NERVOUS DISEASES 

arthritis is characterized by more pain than in arthritis defor- 
mans, also by thickening of the capsule and the ligaments, and if 
neuritis exists with it, a greater wasting of the shoulder-girdle 
muscles. Arthritis deformans also differs from chronic rheuma- 
tism in the existence of extensive structural alterations especially in 
the cartilages, according to Adams. PathologicaUy, too, the 
changes in the joints differ essentially from those of gout in the 
absence of deposits of urate of soda. Xo definite microscopic 
change has been found in the spinal cord in arthritis deformans, 
although there must be some morbid physiological process here as 
a causative factor of this singular affection. 

Treatment. — It is an incurable disease. Much can be done 
towards alleviating the sufferings, however, or to arrest its prog- 
ress. Iodide of potassium or sodium, quinine, the salic^dates, and 
arsenic are all valuable. The use of tonics, and particularly the 
hypophosphites, is of value in supporting the system and in sup- 
plying the waste of salts from the nervous tissue. Syrup of the 
iodide of iron I have found one of the most useful drugs to cor- 
rect anaemia, and with restored blood pabulum the progress of the 
disease is often stayed. Morphine in small doses by the mouth 
often has a favour.able effect upon pain, and in some unknown 
fashion may tend to check the affection. Bloodless operation of 
extension, or a tenotomy, are means to help these people to get 
about on their feet. The accompanying illustrations show well a 
girl who had been bedridden for two years, a helpless cripple. 
She now is able to walk about alone, first having had hyperex- 
tension and tenotomy performed by Dr. C. H. Frazier, then casts 
applied, and finally braces adjusted. The ankles and feet were free 
of disease. The back cases offer little help from the surgeon. 

HEAT EXHAUSTION 

This is a collapse induced by excess of heat to the body, induced 
through natural telluric conditions, or by artificial heat, as an 
overheated room. It is generally associated, however, with the 
state produced by the excess of sun-rays. The condition heat ex- 
haustion is allied to sunstroke, the clinical difference being in the 
aetiology — i. e., the heat has not been so intense as a rule or the 
patient is more resisting; and secondarily in the symptomatology 
in particular: heat exhaustion being a complex where there is 



VASO-MOTOE AND TROPHIC DISORDERS 341 

subnormal temperature of the body, feeble pulse, a status much 
allied to shock, the patient being attacked rather suddenly. He 
complains of headache and faintness, and occasionally he may lose 
consciousness for a short time. The duration may be from an 
hour or so to many hours. The pathology merely consists of a 
disturbance of the heat centres and vaso-dilatation through the 
development of toxins, on account of superheating of the body. 

Prognosis. — This is good if the patient is not re-exposed to the 
heat, and fatty heart or nephritis are absent. 

Treatment. — This is the same as in shock — ammonia, strych- 
nine, and quietude. 

SUNSTROKE 

Thermic fever ; Heat-stroke; Coup de soleil ; Insolation 

This is due to a more intense or more prolonged application 
of heat to the body, as seen under the heading of heat exhaustion. 
The symptoms consist of a feeling of congestion of the brain, mud- 
dled thoughts, as the patient will tell you afterward, and a sense 
of extreme weakness, he usually falling over at his occupation into 
an unconscious state in this period. He may pass at once into 
severe tonic and clonic convulsions. The temperature rises to 
102° or 103° F., gradually increasing until it may reach 109° or 
more; the highest case authenticated and followed by recovery 
being 112° F. Ursemic symptoms usually complicate the disease, 
due to the fact that the renal circulatory apparatus is disturbed, 
and occasionally marked transient albuminuria will be found. 
The duration of the affection is apt to be short and fulminating, 
Ihe patient either recovering after a few days or death may super- 
vene before this time. In those cases that recover there is a great 
liability for relapse or for a chronic meningitis to be set up. 

Prognosis.'^ — Cases with prolonged unconsciousness or suffer- 
ing from a high temperature usually prove fatal in 75 per cent of 
the cases. Cases with high tem_perature and preservation of men- 
tal faculties are more favourable. When there is a failure of the 
kidney, determined by carefully examining the urine, the prognosis 
can be put down as also being bad. In every case there is a great 
liability to relapse on slightest exposure, and in a great number of 

^ The statements in this paragraph are made from a careful study of 30 
cases at St. Agnes's Hospital in 1896. 



342 TEEATISE OX NERVOUS DISEASES 

cases there is a great liability to heat exhaustion or sunstroke at 
subsequent periods. Chronic headache usually follows. 

Pathology. — There must be some chemical change in the body 
causing paralysis of the centres; thus more heat is produced than 
normally. 

In those cases that recover there is a great liability for a 
chronic meningitis to be set up in time, which may be incurable. 

Treatment. — This consists in the application of cold, prefer- 
ably moist cold, in the form of an ice-bath. This should be asso- 
ciated with friction to the extremities with ice. The head should 
particularly be kept cold in order to prevent aggravation of the 
cerebral congestion. Antipyretics are of value in sthenic cases. 
Convulsions must be controlled by the use of chloral and bromides, 
given per orum, or per rectum in the instances where the patient 
cannot swallow. Rectal feeding should also be employed in those 
cases where the stomach is irritable, and in all cases the food should 
be simple, such as peptonized milk, etc. The patient would better 
change his occupation to prevent recurrence. 

MYASTHENIA GRAVIS 

By this disease is meant the peculiar condition in which the 
patient loses power, periodically and suddenly, in the muscles with- 
out any definite neurological symptoms. It is closely allied if not 
identical with periodic paralysis, as described by Taylor, of Bos- 
ton, and studied also by J. K. Mitchell, of Philadelphia. 

The symptom is palsy; the patient on waking in the morn- 
ing finds that he is unable to move the muscles of certain parts 
of the body- or of the entire voluntary musculature. This may last 
for a few to twenty-four hours, or even several days. In a very 
short time the case is perfectly helpless, without any sensory or 
psychic disturbances, save an indefinite paraesthesia or a mental 
anxiety not due to brain disease, but to the fear he naturally has 
of impending death. The patient slowly recovers from the con- 
dition, and may go about his duties as usual within the space of a 
few days, only to be stricken down again at any time. Undoubt- 
edly the underlying condition is an auto-intoxication, either from 
waste products from within or from absorption from without. 
Study of the blood has been made, and nothing has been found 
excepting a mild leucocytosis during the attack. As there are no 



VASO-MOTOR AND TROPHIC DISORDERS US 

temperature symptoms, it is not a condition of sepsis, at all events. 
It is more likely a failure of the normal chemical changes in the 
nervous system, and therefore inability to carry on the function 
of the neuron, although the expression of this seems to be alone 
confined to the muscles. It should also be mentioned that there 
is no reaction of degeneration, though the reflexes are absent. 

Prognosis. — This is very dubious, and the disease may last for 
years, the patient dying in an attack or of some intercurrent affec- 
tion. Ultimate recovery may take place in those individuals where 
the normal metabolism becomes restored. 

Treatment. — This consists in the greatest hygienic care as to 
proper nourishing, protection from cold and dampness, prevention 
of overwork, both mental and physical, and particularly to dietet- 
ics. The food should be simple, consisting largely of proteids, as 
milk, eggs, and those substances containing excess of nuclein — 
beans, peas, etc. — also those containing iron, such as spinach,, 
although the patient should never eat too heartily. During an 
attack the patient should be kept in bed. Strychnine is given 
in doses of -^ grain up to -yV grain hypodermically. While 
venesection would be a dangerous procedure, the use of hypoder- 
moclysis of salt solution or even transfusion, if this can be prop- 
erly done, would be of great value. This subject has not been suffi- 
ciently worked up by the surgeon. It is to be recommended as an 
ideal treatment in this disease. The use of thyreoid extract, 
thymus gland, or even suprarenal extract capsule preparations 
sometimes seem to meet the conditions and probably be of value 
in aiding metabolism. Bone-marrow is another organic prepara- 
tion that may be of value. The bromides were valuable in a num- 
ber of the cases coming under the observation of Holtzapple, which 
is probably due to restoration of vaso-motor tone in the motor 
horns of the cord. 

FAMILY PERIODIC PARALYSIS^ 

Cases of this rare disease have been detailed by Putnam and 
John K. Mitchell and others. The pathology of the affection is 
unknown ; blood examinations have shown no characteristic 

^The valuable paper read by Dr. G. E. Holtzapple, of York, Pa., at the 
meeting of the Medical Society of Penna., Sept. 24, 1903, throws more clinical 
light on these enigmatic diseases than has yet been given to the profession. 



344 TREATISE ON ^N^ERVOUS DISEASES 

changes, nor has the urine. Some undiscovered toxin, probably of 
autochthonous origin, is the cause; a tendency to degeneration of 
this sort passing from one generation to the next. (See Myas- 
thenia gravis, from which it differs by being a family disease.) 

Symptomatology. — It consists of periodic attacks' (of more or 
less sudden onset) of wide-spread flaccid motor palsy, associated 
with loss of knee-jerks and electrical excitability, with little sen- 
sory or psychic symptoms of any kind. The attacks begin in the 
majority of cases between the second and third decades of life. In 
some cases there are prodromata, such as a feeling of weariness, 
formications, numbness, headache, backache,, sweating, and loss of 
vaso-motor tone. As a rule the paralysis begins when the physio- 
logic ebb is lowest — i. e., at night — and continues for several hours 
before the acme of the paralysis has set in. The legs are usually 
first affected, then the muscles of the arms, trunk, and neck in 
severe cases. The cranial nerves usually escape palsy. During the 
attack there is loss of knee-jerk and absolute loss of electrical irri- 
tability of the muscles, without degenerative reaction, however. 
But in the interval between these attacks the reflexes and elec- 
trical irritability are normal. In some cases during an attack 
myocardial weakness is found, the heart may become dilated, and 
haemic murmurs (usually a mitral systolic murmur) are found. 
This also disappears with the normal intervals. The patient is 
mentally apathetic during attacks, but never further affected as to 
his mind. The usual duration of an attack of transient paralysis 
is from five to thirty-six hours. Recovery from the attack takes 
place gradually. Each succeeding attack may become more pro- 
found, leaving the patient in a more marked asthenic condition. 
It is incurable. Treatment during attack should be hypodermics 
of strychnine and digitalis, bromides, warm baths, and effleurage. 
Hypodermoclysis of normal salt solution may aid recovery. Thy- 
reoid should be tried. The disease should practically be managed 
as is a case of myasthenia gravis, already studied, and from which 
it differs again in the more pronounced periodicity. (See p. 343.) 



CHAPTER XVIII 

GENERAL TOXEMIC DISEASES OF TEE NERVOUS 
SYSTEM 

HYDROPHOBIA-RABIES 

Hydrophobia, or rabies^ is a con^^llsive disease induced by the 
virus of a rabid or " mad " dog. The disease primarily must origi- 
nate de novo, more particularly in the canine. The infection is 
more frequent in hot weather^ when the condition of the blood of 
the animal favours the growth of the germ. As yet this has not 
been isolated. The name hydrophobia is a misnomer, in the fact 
that the patient does not have the fear of water, per se; but in the 
symptomatology of the disease, the spasm of the pharyngeal mus- 
cles prevents deglutition and makes the swallowing even of liquids 
difficult or impossible. The usual method of inoculation in the 
human being is by means of the bite of a " rabid " or delirious 
dog. As a rule, the wound is slight, so that frequently little atten- 
tion is paid to the point of infection. Where the wound has been 
freely opened or cauterized immediately after its inception, the 
less is the possibility of development of rabies following the bite of 
an animal suffering from hydrophobia. 

Symptoms. — Development of the symptoms of rabies seldom 
takes place sooner than six weeks or after three months from 
the date of infection. The patient is suddenly seized with ex- 
treme nervousness and excitability; the muscles remain rigid, 
especially those of mastication and the constrictors of the phar- 
}Tix; the head is drawn back in tonic spasm. The patient com- 
plains of his inability to use his extremities well on account of 
" stiffness " ; the mental anxiety apparently progresses out of pro- 
portion to the severity of the disease, and in these cases, no doubt, 
the apprehension of the terrible malady produces a species of 
hysterical insanity complicating the rabies. Within a few hours 
the patient may go from the tonic convulsion into violent clonic 

345 



346 TREATISE ON NERVOUS DISEASES 

spasms i and these maybe brought on, too, by slight sources of 
reflex disturbance, such as loud noises, sudden throwing of light 
upon the patient's sensitive retina, or as in attempting to cath- 
eterize the patient, which is sometimes necessary, due to spasm of 
the sphincter vesicas; all of these reflex convulsions being the 
result of excitation, of the hypersensitive special sense and general 
sensory neurones. The patient's mental condition gradually be- 
comes maniacal, and he tosses about the bed in fear and delusion; 
there is a prominent feeling of impending death due to contrac- 
tion of the throat muscles and those of respiration, and even the 
diaphragm; while the cardiac arrhythmia and cramp produce 
symptoms allied to angina. Any attempt at swallowing, as before 
indicated, will cause an aggravation of the throat symptoms, 
although the natural desire to obtain liquids is really nature's 
effort at producing dilution of the poison in the system, which 
is defeated by the inability to perform the act of deglutition. 
Opisthotonus is not an unusual position for the body to as- 
sume in the interim of clonic spasm, the trunk rigidity always 
remaining, with but little relaxation; or the body may be drawn 
in emprosthotonus or pleurothotonus, depending upon the mus- 
cles of the trunk more particularly affected. This sudden cramp- 
ing of muscles in the various parts of the body causes violent pain, 
so that when the mentality is not entirely blunted there will 
be produced evidences of extreme suffering in the face aside from 
the general spasm of muscles of expression. The temperature 
rises in irregular fashion to 103° or 104°, and is proportionate 
to the degree of infection, especially to involvement of cerebro- 
spinal meninges. If the patient does not die of exhaustion in the 
convulsions at the end of the third day the paralytic stage sets in, 
the temperature drops, the muscles become flaccid, the patient 
enters into low muttering delirium in profound unconsciousness, 
showing extensive degeneration of the cerebral cortex; finally he 
dies of exhaustion, the heart generally stopping before respiration 
has ceased. Risus sardonicus usually precedes death. 

Diagnosis. — The only disease with which it can be confounded 
is the one we shall next discuss, tetanus, symptoms of which, when 
given, will fairly accurately set aright this differentiation, which 
lies particularly in the mode of infection and in the stage of 
invasion of the acute symptoms. Hysteria may simulate. 

Prognosis. — The prognosis of hydrophobia is almost univer- 



VASO-MOTOR AND TROPHIC DISORDERS 347 

sally fatal. Some mild cases have no doubt recovered under treat- 
ment, just as rarely occurs in tetanus under the most active thera- 
peutic measures. 

Treatment. — Treatment is preventive. The antitoxine method 
discovered by Pasteur is the only measure certain of saving 
the patient. It should be resorted to immediately upon learning 
the true nature of the disease in the animal that has been the 
source of infection; and in view of the severity of the malady, 
should be done without delay where there is even suspicion of 
rabies. The antirabies serum should be injected according to the 
dosage prescribed by the laboratories where it is prepared; that of 
Gibier in this country being the most desirable product. Treat- 
ment after the development of the disease is entirely sympto- 
matic, the use of cannabis indica, of the Calabar bean, the bro- 
mides, and chloral being indicated. Guarding the patient from 
noises or extremes of light or cold is an essential point in amel- 
ioration of the terrible symptoms of this, until recently, usually 
incurable disease. 

TETANUS 

Lockjaw 

Tetanus, or lockjaw, is a disease characterized by violent con- 
vulsive seizures beginning in the muscles of mastication; hence the 
name lockjaw. Consciousness is preserved. 

Etiology. — The cause of tetanus is a ^short, rod-shaped bacil- 
lus, whose habitat is in the earth. For this reason gardeners and 
hostlers are particularly susceptible to infection. I have in mind 
the instance of a splinter which produced tetanus when run under 
the nail of a farmer while in his stable ; and another case of a boy 
who received a brush burn over the tibia while driving mule-cars 
in a coal-shaft. Penetrative wounds, as by a nail, are also sources 
of inoculation. The incubation of lockjaw is much shorter than 
that of hydrophobia, being an average of ten days until invasion 
of active symptoms. 

Symptomatology is indicated in the definition. It begins with 
rigidity of the jaw (trismus); difficulty in swallowing; "stiff- 
ness " in the back of the neck, the patient often complaining 
at the outset of simply an inability to move the muscles well on 
account of this rigidity. Soon the muscle rigidity becomes gen- 
eralized, and there is a tonic contraction of the entire muscula- 



348 TREATISE ON NERVOUS DISEASES 

ture, interspersed with twitcMngs of the small muscles of the ex- 
tremities; with this there is great mental anxiety, but the mind 
remains perfectly clear. The disease rapidly progresses, clonic 
convulsions occur in which the patient suffers violent pain and 
cries out in his torture, although efforts at clear phonation are 
interfered with by spasm of the pharyngeal and laryngeal mus- 
cles. There is forcible dejection of urine and fseces, also abort- 
ive efforts at vomiting. With sudden noises, as the slamming of 
a door, or throwing of light upon the patient, the subject will 
go into violent convulsive seizures of a clonic nature. The 
patient will be at times painfully contorted in various parts of the 
body, the picture finally ending with general convulsions, as above 
stated. There is a continuous tonic contraction during the active 
course of the disease. There is general hypersesthesia, and also 
enormous excitability of the special senses, such as photophobia, 
etc. At intervals between the serious motor explosions, and even 
under the effect of enormous doses of depresso-motors, the patient 
may get a few moments of disturbed slumber, only to be aroused 
by a sudden convulsive attack. The progress of the case is grad- 
ually downward, the patient finally at the end of three or four days 
going into collapse, with slight relaxation of the muscles and drop- 
ping of the temperature below normal. The algid stage now super- 
venes, also risus sardonicus, death soon following from exhaustion. 
[Cephalic, or Rose, tetanus is a chronic form of subacute tetanus 
in which trismus is the prevailing symptom. The course is longer 
(weeks), prognosis good, and treatment (same as tetanus) usually 
curative. A case of Rose tetanus under my care, that of a physi- 
cian, caused by a kick on the nose by a mule, recovered promptly.] 
Treatment is as yet but symptomatic and very unsatisfactory, 
since the cultivation of the tetanus bacillus cannot be grown out- 
side of the human body ; also, as we have not been able to produce 
the disease in mild enough form in the lower animals to avoid 
death, the antitoxine has not been obtained. With the rapid ad- 
vances in bacteriology, it is to be hoped that such antitoxine will 
be produced in the near future, when we will have a prospect of 
successful treatment of this terrible malady. The treatment at 
present to be adopted is immediately to open up a wound where 
from the above pointed-out sources of infection any such wound 
exists. Even after the tetanic symptoms have developed, it would 
be wise, though late, to excise such a wound in the hope of staying 



VASO-:\r()T()K AND TKOPITIO DTSOKDEKS 340 

further infection from the nidus. The patient suffering from 
tetanus should be placed in the quietest possible surroundings; 
the room should be thoroughly shaded and kept entirely quiet 
from all sources of reflex irritation through the general or special 
senses ; the slamming of a door I have seen the cause of precipitat- 
ing a convulsion. Chloral is in my experience one of the best 
drugs at command for the alleviation of convulsion, and while the 
heart may be depressed, the excito-motor system is so stimulated 
in this disease that the use of such depressant far surpasses any 
ill effect upon other organs, as the heart. This drug can be given 
in 15-grain doses every three hours, and pushed until some amel- 
ioration of the convulsive seizure obtains. The remedy can, in cases 
where the patient is unable to swallow, be administered per rec- 
tum, and in this case should be given in about twice the dose as 
when taken by the mouth. Bromides take second place in the 
management of the disorder, and can be combined with the chlo- 
ral in cases where the former fail. By such combination we have 
ideally what H. C. Wood terms the " crossed '"' action of drugs — 
that is, the maximal effect upon one part of the system, in this 
case the depression of the motor centres in the brain, with a mini- 
mal effect upon, as in this case, the cardiac and respiratory func- 
tions. Morphine should be used hypodermically with caution 
where the case is in a status of convulsions, the idea being here 
to quiet the nervous S3"stem quickly in order to prevent death 
through continuation of convulsions and consequent exhaustion. 
This drug should not be used in the interim, since it is not de- 
sirable to block the kidneys in any way. Venesection in tetanus 
would seem to be rational therapeutics, for by this measure we 
could hope to carry off the toxine in part, and by hypodermo- 
clysis possibly to dilute the blood pabulum and flush out the 
toxine from the nerve-centres in the brain and cord. The prin- 
cipal drawback in the procedure would be the tonicity and spasm 
of Mie muscles and blood-vessel walls which prevent both the 
egress and ingress of salt solution.^ Calabar bean I have seen 
cure one case. It should be pushed, in the form of the fluid 
extract, to the physiological limit in cases where the chloral, 
bromide, and opium treatment outlined has failed to produce 
any amelioration of symptoms within the first twenty-four hours. 

1 Normal salt solution is prepared by adding 46 grains of sodium chloride 
to the pint of distilled water. The water is kept at 110° F. 



350 TREATISE ON NERVOUS DISEASES 

It should be mentioned that such patients ought to be espe- 
cially guarded from hurting themselves, for while they are per- 
fectly conscious and appreciate the terrible suffering, they are, of 
course, unable to protect themselves from injuries resulting from 
the violent convulsions. The- tongue should be particularly guard- 
ed from being bitten, and the saliva should be kept clear from the 
throat, more by the posture of the body (preferably placing the 
patient on his side from time to time) than by any effort at 
mechanical swabbing of the throat. The bed should be very large, 
soft, and placed in the centre of the room, so that attendants can 
relieve and guard the patient from all sides. If hyperpyrexia 
should develop, the application of ice-bags to the head and spinal 
column would be of value. 



TETANY (TETANILLA) 

Tetany is a subacute or chronic disorder that is characterized 
by intermittent or persistent tonic contractions beginning in the 
extremities and associated with paraesthesia and hyperexcitability 
of the motor and sensory nerves. 

etiology. — It is a rare disease in America, but quite common 
in Europe, especially in Austria. It is more common at the sec- 
ond to fourth years of life, and again at the age of puberty, and is 
very rare after fifty years of age. It is more frequent in males 
in early life. There is less difference in the frequency of its 
appearance in either sex after the twentieth year. Rachitis is a 
predisposing cause. Exciting causes are exhausting influences, like 
lactation, sepsis, fatigue, mental shock, fevers, or exposure to cold 
or wet. Dilatation of the stomach and absorption of toxines from 
the intestinal tract in consequence, intestinal parasites, and alco- 
holism may also cause the disease. 

Symptoms. — The attacks are usually paroxysmal, lasting from 
a few minutes to many hours. In the continuous cases the sp^sm 
may last for days or weeks. There may be a feeling of general 
lassitude or of numbness or pain in the extremities for a short 
time before the onset. In the majority of cases the spasms are 
confined to the hands alone or to the hands and feet. The fingers 
are closely pressed together, the thumbs adducted and pressed 
against the index-finger, the so-called writing posture ; or are flexed 
into the palms beneath the fingers, the so-called " accoucheur's 



VASO-MOTOK AND TUOPTTIC DTSOHDKRS 351 

hand/" The forearm is flexed and upper arm adducted. In 
the lower extremities the toes are strongly flexed, the knees and 
feet extended, the feet also being inverted. In bad cases the muscles 
of the abdomen, chest, neck, and face are involved. Trismus and 
drawing out of the angles of the mouth give a peculiar physiog- 
nomy to the patient (risus sardonicus). Opisthotonus and dyspnoea 
may result. The orbicularis oris and extra-ocular muscles may 
develop contractions, closing the eye, thus adding a squint to the 
patient's grotesque appearance; the muscles of the larynx (laryn- 
gismus stridulus), oesophagus, and bladder may be affected. There 
is no pain unless the spasms are severe. Fibrillary tremors may be 
seen in the contracted muscles. There may seldom be loss of con- 
sciousness, and this usually occurs in the cases associated with 
extreme debility or gastrectasia. Usually the mind is quite clear. 
There may during attacks be hyperesthesia of the skin of the parts 
affected. The spasms may arouse the patient from sleep. Fever 
is at times present in epidemic form. In such there must be some 
mixed infection complicating the case. 

(A) In the intervals between attacks continued pressure over 
a nerve-trunk may bring on spasms (Trousseau s sign). Even a 
slight tap over a nerve with the plexor may induce spasm of the 
muscies supplied by it. Thus tapping over the facial nerve at its 
point of exit from the stylo-mastoid foramen will produce contrac- 
tion of the muscles of the face, particularly of the lips. This is 
called the facial phenomenon or Chvostek's sign. 

(B) Electrical excitability (electrotonus) of the motor nerves 
and muscles is increased, a feeble current causing tetanic contrac- 
tions. Instead of the normal formula we may have AnClC or 
AnOC>IvClC. This is called ErVs symptom. There may be 
a cathode-opening tetanus, a phenomenon not found in any other 
affection. Gowers says there may be a reversal of the polar for- 
mula. Thus a positive-pole opening contraction occurs earlier 
than' a positive-pole closure contraction. 

(C) Sensory nerves are also more irritahle to mechanical and 
electrical stimuli ; a weak current passed through such a nerve 
as the supra-orbital may cause paraesthesia in the parts to which the 
nerve is distributed. This is called Hoffman s symptom. The 
auditory nerve reacts easily. In exceptionally mild cases the symp- 
tomatology of tetany may be of paraesthesia and stiffness of mus- 
cles without real spasms. In this latter form Trousseau's symp- 



352 TREATISE ON NERVOUS DISEASES 

torn cannot be elicited. Infantile tetany is less apt to be severe 
than that in youth or adults. Symptomatic tetany from brain 
disease must be differentiated from true tetany principally by the 
presence of the brain disease and trismus. 

Duration. — When the spasms are continuous the disease lasts 
but a few weeks, but when they are intermittent they may last for 
months, as though it took a certain time for the toxine to be elimi- 
nated, and in which the spasm assisted in some unknown fashion. 
(Epilepsy may also be bettered by an occasional attack in toxic 
cases.) 

Tetany usually lasts a few weeks or several months. It is 
liable to recur on a return of the exciting cause. 

Diagnosis. — The disease is usually told by the symmetrical 
distribution, the hyperexcitability of muscles, motor and sensory 
nerves. Trousseau's sign is found in no other affection; also it 
is very rare to find the " facial phenomenon '' and the electrical 
and mechanical irritability of such quality in any other disease. 
The acoustic-nerve irritability is also characteristic. Tetany 
rarely causes death. Tetany is distinguished from tetanus by 
the intermittent tendency of the spasms, their feeble character, and 
the fact that they begin in the extremities and extend to the 
trunk; also the absence of trismus except very late in the disease. 
It may recur annually for a number of years. 

Pathology. — There is a congestive and irritative condition of 
the gray matter of the spinal cord. In epidemic tetany there must 
exist some infectious poison. In other cases mucin circulation in 
the blood is found, as in that type due to thyreoid disease {thy- 
reoid tetany). Rheumatic poison causes other cases of tetany. 
Ergot may produce symptoms resembling tetany. In infantile 
tetany the irritation is due to cortical affection, to meningitis, 
rachitic poison, or to reflex irritation from disorder in the gas- 
tro-intestinal tract. The latter scarcely ever happens in adults. 
Tetany is a symptomatic disease, but the primary causes are so 
many it deserves the distinction of a name on clinical grounds. 
There is no definite pathology, no characteristic constant lesions 
being found at autopsy. 

Treatment. — Stop the cause, having searched most carefully 
for it. In cases following the removal of the thyreoid or due 
to disease of that organ, thyreoid extract should be given. Lacta- 
tion must be stopped in adults. Diarrhoea, indigestion, or rickets 



VASO-MOTOR AND TROPHIC DISORDERS 353 

should be cured, or removal of intestinal parasites if existent. 
Symptomatically : Rest, nourishing food, tonics; and for the 
spasms, bromide of sodium in 1-dram to 3-dram doses combined 
with chloral for its " crossed action '' are indicated. Hyoscine 
hydrobromate, grain yJ^ t. i. d., may be of service ; or valerian or 
other antispasmodics may be employed. Warm baths are of serv- 
ice. Digitalis is of value in nocturnal tetany, as advised by Gow- 
ers. This dose given at bedtime very likely acts through toning 
up the circulation and hastening elimination of the poison. The 
anodal pole of a weak galvanic current may allay the irritabil- 
ity for a time. Inhalations of chloroform or ether may be neces- 
sarv to control the convulsive seizures. 



23 



CHAPTER XIX 
DRUG INTOXICATIONS 

ALCOHOLISM-ALCOHOLIC INSANITY 

This is a disease produced by indulgence in spirituous liquors. 
There are two sorts: acute and chronic. The acute is usually 
brought on by the excessive indulgence at periodic intervals, the 
chronic by the result of more or less constant imbibition. The de- 
velopment of these conditions will depend more or less upon the 
idiosyncrasy of the particular individual. Those forms of alcohol 
containing fusel oils are more apt to precipitate an attack. 

Symptoms of Acute Form. — The patient complains of con- 
fusion of ideas, is mentally excited, the sensorium, however, gen- 
erally being obtunded, so that exposure to cold, for example, is 
not well appreciated. There will usually be fine tremor of the 
extremities, lips, tongue, in the acute alcoholic state. The urine 
will be found to be of a high specific gravity and often loaded with 
uric acid, especially with those who have a lithsemic diathesis. 
The patient will complain of a full feeling in the head, often of 
palpitation of the heart and symptoms of acute indigestion, such 
as nausea and vomiting, followed by a thin and watery stool. This 
syndrome of symptoms is followed by general muscular weakness 
and exhaustion. The clinical picture may last from a few days to 
many weeks, depending upon the continued indulgence in alcohol. 
At any stage of the disease the patient may develop manm a potu 
or delirium tremens, which is characterized by great mental and 
physical excitement, by hallucinations and delusions, particularly 
of seeing weird objects (the seeing of snakes), this being rather a 
constant illustration. The patient also hears uncanny voices or 
may describe actual voices, such as that he hears people plotting 
against him. With this there is a rapid progressive weakness, and 
the patient may fall into dementia and death result from, failure 
of the nerve-centres or from an intercurrent pneumonia, especially 



ALCOHOLISM 355 

if he has exposed himself greatly. The kidneys may fail and the 
patient go into a state of uraemia, which latter will be the cause 
of death. 

Prognosis. — This is good as to recovery if the patient's consti- 
tution is sufficiently vigorous, but the danger of relapse is always 
probable. Cases of mania a potu should be guarded in prognosis, 
since the patient may die of a complication, or a permanent de- 
mentia may be the sequel. Mild cases usually recover. 

Pathology. — There is an alcoholic poisoning of the nerve- 
centres, producing a chronic congestion of the meninges and the 
brain, and in the worst cases fatty degeneration of the cortical cen- 
tres or neurones and the same parenchymatous change in other 
parts, as the liver and kidneys. 

Treatment. — This consists of in the first place withdrawing 
the drug, which can be done in two ways, (1) suddenly and (2) 
gradually. The former is the most desired method, immediately 
stopping the alcohol, supporting the system by means of strych- 
nine or nitroglycerin ; and by simple food, such as milk, etc. Tor 
the mental excitement, chloral and bromides in combination are 
ittdicated. Hyoscine hydrobromate in -gV'g^- doses hypodermically 
is often of great value. The gastro-intestinal tract should be 
treated carefully ; the use of the blue-mass pill, 5 grains, repeated, 
should be resorted to wliere the intestinal tract is sluggish. This 
should be followed by vegetable tonics given before meals. The 
patient should be kept quiet and exposed to sunlight and fresh air 
as much as possible. The kidneys should be treated. 

Symptoms of the Chronic Form. — These are the same as in the 
acute form of poisoning, but in less degree. The somatic symp- 
toms predominate ; and the mental consist of obtundity, or of de- 
mentia in the worst cases. In others the mental symptoms produce 
the chronic alcoholic insanity or mania, w^hich is a type of excita- 
bility or excitable insanity with delusions, and is probably due to a 
chronic irritation of the cortex from meningeal thickening or 
patches of cerebral sclerosis. 

Diagnosis of any form of alcoholic poisoning will largely de- 
pend upon the history of the case and upon the detecting of the 
drug upon the breath. This, together with the physiognomy of 
the patient, of acne rosacea, or evidence of congestion of 
the brain, liver, or kidneys, will make positive the source of the 
disease whjen taken with the symptoms detailed. 



356 TEEATISE ON XERVOrS DISEASES 

Prognosis of the Chronic Form. — The chronic form is apt, 
unless the drug is withdrawn or withheld entirely, to end in 
fatty degeneration of the brain, heart, etc. This fatty degenera- 
tion of the organs of the body and neuritis will occur if the 
poisoning continues. Chronic alcoholic mania very seldom, if ever, 
recovers. 

Pathology, — Congestion of the meninges of the brain and cord, 
endarteritis, periarteritis, and sequent fatty degeneration of the 
brain and various organs of the body, occasionally accompanied by 
circumscribed htemorrhages, are all found: as in pachymeningitis 
ha^morrhagica interna, the symptoms of which are given in an- 
other place. Cloudy swelling of the kidneys, the heart, and liver 
occur ; while chronic gastritis and enteritis may complete the path- 
ological picture. 

Treatment. — The treatment of the chronic form is largely 
hygienic and supportive. Alcohol should also be- withheld entirely, 
as in the acute form of poisoning. Xitrate of strychnine is the 
drug par excellence. It is best given hypodermically in g^o-grain 
doses. The uses of cocaine ^ or strong infusion of coffee is of great 
value as a stimulant in those cases liable to depression after the 
withdrawal of alcohol. Chronic alcoholic insanity will require 
treatment in an asylum. Eesultant nlcoholic netiritis has been 
treated under another heading. (See Xeuritis.) 

TOBACCO POISONING 

Acute poisoning frequently presents marked symptoms through 
reflex nervous influence, such as tachycardia, irregular pulse or 
heart, and palpitation (symptoms that also exist in the so-called 
tobacco heart in chronic poisoning). There may also be disturb- 
ances of respiration, mental excitement, and tobacco amblyopia, the 
latter being common. The poisoning takes place in people who are 
smokers, or in those who handle tobacco largely, as cigar-makers. 
The duration of symptoms may be indeflnite, and will depend upon 
the amount of tobacco smoke inhaled and the idiosyncrasy of the 
patient for or against the drug. The tobacco heart is of chronic 

^A. J. Hall (Medical News, October 31, 1903) credits caffeine with a 
physiologic antagonism to alcohol in doses of gr. j or gr. ij every one, two, or 
three hours. The author contends that in twenty-four or forty-eight hours 
the drug will effectually quench the craving for alcohol in confirmed habifues. 



TEA, COFFEE, MERCUKY, AKSENIC POISONING 357 

nature, often lasting for many months or several years after com- 
plete withdrawal of the poison. Cardiac hypertrophy may occur 
in it with all the physical signs of heart disease. 

Diagnosis. — This is to be made from chronic tea poisoning, 
which is associated more frequently with chronic dyspepsia, in 
which latter the amblyopia almost never occurs. 

Pathology. — This consists in an auto-intoxication, which may 
set up fatty degeneration in various organs of the body. 

Treatment. — Withdrawal of the tobacco, and supportive meas- 
ures with nutritious diet are indicated. In tobacco heart it will 
be necessary to administer vaso-constrictors, as digitalis, strophan- 
thus, etc. ; together with rest, fresh air, and sunlight. 

TEA AND COFFEE POISONING 

Tea and coffee are drugs which very frequently produce symp- 
toms in the nervous system. The symptoms produced are mental 
excitement, insomnia, tremor, and irregular cardiac action. These 
are rare, but they should be looked after and attended to in order 
to prevent bad results. Treatment would be the same as for 
tobacco poisoning. 

LEAD, MERCURY, AND ARSENIC POISONING 

A remote common result of these poisons is multiple neuritis. 

The S3aTiptoms of lead encephalopatliy are special symptoms of 
chronic lead poisoning, and consist of mental excitement (mania), 
or general or localized cerebral convulsions, and are usually asso- 
ciated with marked arterial sclerosis set up by the lead. In the 
pathology of this condition there is also a thickening of the 
meninges, and later in the course of the disease there is a fatty 
degeneration of the neurones. The prognosis of the disease is bad. 
The patient may live for many years, however, finally passing into 
secondary dementia. The treatment should be supportive and 
eliminative, as potassium iodide for continuous periods. If the 
mental symptoms predominate, then the same treatment as in 
insanity should be resorted to. 

Mercury and arsenic seldom produce nervous symptoms other 
than the neuritis indicated. The importance of the blue line in 
chronic lead poisoning and the waxy condition of the skin and the 
ptyalism produced in mercury are all points which will assist in 



358 TREATISE ON NERVOUS DISEASES 

making the diagnosis. In arsenic poisoning a point to be taken 
into consideration is the oedema of the lids (the lower) of the eye. 
In all of the above poisoning symptoms gastric signs may be 
expected. 

OPIUM POISONING 

This manifests itself in the nervous system in the forms of 
acute and chronic poisoning. 

Symptoms of Acute. — These are slowness of the pulse and res- 
piration; the former may go down to 40 or 50 and the latter to 
,10 or 12 per minute. The patient becomes comatose/ the lips and 
extremities may become cold, and especially the former bine; 
besides, the patient may be breathing in a stertorous manner; the 
secretions of the body are checked, and the pupils become con- 
tracted or " pin-pointed." The onset is rather slow and follows 
some hours after the ingestion of the poisonous drug. Even in 
the milder cases it is difficult to arouse the patient. While he may 
appreciate his danger, yet the desire for sleep is so irresistible that 
he will not make any effort to remain awake even where there is no 
intended suicide. One grain of sulphate of morphine may produce 
these symptoms, or from 3 to 10 grains of powdered opium, or 
smoking of the drug, as a habit. In some cases from the reten- 
tion of urine there is soon set up a cystic irritation. 

Symptoms of Chronic. — The evidence of chronic opium poi- 
soning on the nervous system is shown in mental hebetude, vacilla- 
.tion, etc. The patient is inattentive, generally manifesting to 
a marked degree a condition of ego ; but is indecisive, and also 
cannot, as a rule, advance into new fields of work, similar to that 
condition existing in paresis. Such a patient's secretions and 
excretions become scanty, the skin becomes dry and hard, and the 
physiognomy loses animation, the pupils becoming and remaining 
contracted. The patient may sit for hours in a " dopy '' condition, 
again at times being vivacious, especially after taking another por- 
tion of the drug. It is usually, in most of the cases, seen to be the 
result of hypodermic medication, the abuse of that form of thera- 
peusis. In other cases smoking of the drug is the cause of the 
chronic opium poisoning. 

Prognosis. — This is rather dubious as to recovery in all cases', 
since the patient's condition is usually so corrupted at the time he 
reaches this stage that he is unable to resist the drug which he has 



COCAINE HABIT 359 

been taking. If this can be reduced, however, liability to cure is 
proportionately large. The patients may live for years as chronic 
morphine hahitues. They are liable at any time to attacks of con- 
gestions and low-grade inflammations. 

Treatment. — This consists in withdrawing the drug rapidly and 
completely, and in addition supportive measures should be resorted 
to. In some cases mental therapeutics, as through hypnotism, 
suggesting to the patient while in a hypnotic state that he will not 
be further able to enjoy the use of the drug, will sometimes be of 
avail. Hyoscine hydrobromate is the only drug that may act as 
a specific. It should be given in full dosage. 

COCAINE HABIT 

The abuse of cocaine hydrochlorate has become frequent in 
recent years. Often the hahitue has taken the drug as a substitute 
for opium or some of its alkaloids. Or, again, the habit may have 
been formed through a patient having taken the drug locally for 
relief of pain, as in cases of chronic neuralgia of the branches of 
the fifth nerve, particularly if associated with chronic disease of a 
tooth or the alveolar processes of the maxillary bones. In other 
cases the habit has been induced through cocaine spra3'-s in chronic 
naso-pharyngeal disease. The drug is usually taken by applying 
pledgets of cotton soaked with 4 per cent or stronger solution to 
the nasal mucous membrane, or hypodermically. 

Symptoms. — The cocaine hahitue usually shows evidence of 
mental excitement, associated with cardiac acceleration or irregu- 
larity. The respirations are hurried, more pronouncedly after he 
has recently taken a dose of the drug ; when also marked mydriasis, 
wakefulness, and a sense of diminution of fatigue and hunger. 
The patient may complain of a sense of " tightness " about the 
chest. The mucous membranes are dry. In advanced cases the 
skin is cold and clammy. Other symptoms are impairment of 
co-ordination, hallucinations, and delirium. Though decidedly 
diuretic, it lessens the quantity of urea by checking the processes 
of waste, thus acting as an indirect nutrient, and enabling the body 
to maintain its energy on a lessened supply of food. On account 
of the increase of cutaneous circulation local flushings may occur. 
From the fact that the hahitue usually tries to conceal the habit, 
observation as to the small amounts of food taken is important in 
diagnosis. 



360 TEEATISE OX NERVOUS DISEASES 

Prognosis. — The cocaine " fiend " is about as difficult to suc- 
cessfully treat as the morphia habitue. Permanent cure is alwa3^s 
dubious. 

Treatment. — An overdose of cocaine must be combated by 
amyl nitrite for the cardiac depression, then alcohol and opium 
as stimulants to the heart ; also artificial respiration. Chloral and 
chloroform are the most directly antagonistic. 

The " habit '^ is best combated by securing full control of the 
patient, such as placing him on rest treatment. The drug must 
be gradually reduced, an occasional dose of morphia given in 
solution that the patient may not detect the substitute. Digi- 
talis in 5-minim doses thrice daily or oftener may be required to 
tone up the circulation. During the period of withdrawal of the 
cocaine the bromides are often valuable to allay cerebral excita- 
tion and produce sleep. The gradual increase of proteid food, as 
eggs and red meats, is important as metabolism recovers. 

COAL-TAR PRODUCTS INTOXICATION 

Under this heading come antipyrine, antifebrine, and phenace- 
tine as true coal-tar derivatives, while the salicylates are more 
strictly of the carbolic-acid series. All of them, when used in 
excess in gradually increasing doses, may be said to exist as a 
'^ drug habit.'' 

Symptoms of Poisoning. — As these drugs are used as valuable 
remedies for pain, the habit is often engendered very insidiously. 
Especially is this so in the hysterical " remembrance pain " follow- 
ing true pain of the various painful affections in nervous disease. 

There is usually no attempt at deception on the part of the 
patient the subject of the coal-tar intoxications, but frequently he 
takes the drug with a feeling of its necessity for the real or " re- 
membrance pain " referred to above, and to which I have called the 
attention of the profession in another place.^ In toxic doses (in 
some cases as much as 100 grains a day of antipyrine in tablets 
has been the limit of tolerance) the patient becomes cyanotic, 
presenting a leaky skin, feeble, running pulse, singing in the ears, 
and a reduction of body temperature -^° to i° F. Occasionally the 

^The Therapeutic Status of the Coal -Tar Products in Central Nervous 
Affections. Symposium of the Phila. County Medical Society, Dec. 10, 1902. 
Vol. IV, New Series. 



COAL-TAK PRODUCTS INTOXICATION 361 

patient is nauseated and vomits. Very rarely there is a peculiar 
erythematous skin eruption noticed over the face, chest, and on 
the sensitive skin between the fingers. There is a depressant influ- 
ence upon the brain. In extremely toxic doses the principal influ- 
ence is exerted upon the blood, altering the shape of the red cor- 
puscles, separating the hematin, and causing decomposition of that 
fluid. 

Diagnosis. — Confusion cannot be made with any other intox- 
ication if the above symptoms are carefully observed. 

Prognosis. — This is, as a rule, good in chronic poisoning, since 
the system has become somewhat immune to the poison. 

Treatment. — Of acute intoxication consists in the administra- 
tion of strong coffee, strychnine, and digitalis, with quietude and 
alcoholic stimulation. In chronic poisoning, the withdrawal of the 
drug gradually, the steadying of the circulation by digitalis or 
strophanthus, quietude (rest in bed), and full feeding are all 
essentials. 



CHAPTER XX 
PARESIS 

GENERAL PARALYSIS OF THE INSANE-GENERAL 
PARESIS-DEMENTIA PARALYTICA 

This is a progressive degenerative disease of the brain, distin- 
guished by abnormal mental symptoms which end in dementia, 
associated with physical weakness or palsy ; also with other charac- 
teristic physical signs and symptoms. It runs a fatal course, of 
about three years' duration in the vast majority of cases. 

etiology. — Paresis, as it is usually termed, is a parasyphilitic 
disease, or, as Krafft-Ebing metamorphorically puts it, a disease of 
syphilization — in consonance with another fact that it 'is a dis- 
ease of modern civilization. A century ago paralytic dementia 
was rare, now it is seen frequently at clinics, asylums, and in pri- 
vate practise. The disease is rare still in Asia and Africa. Cli- 
mate in these countries must have some immunizing influence 
upon the system, since the same cases may be as likely to acquire 
paresis if exposed to specific infection Avhen in Europe or Amer- 
ica. It is a disease of indirect heredity to predisposition — i. e., 
the patient is born with a neuropathic constitution, though it is 
once in a while found to be congenital, occurring in the very young 
whose parents were syphilitic. It occurs almost six times as often 
in the male as in the female. As women take on the follies of men, 
we find the proportion of cases increasing in the female sex. 

Excessive mental exertion, as of the intense mind tension of 
a banker, is a predisposing cause also, as is alcoholism. Sexual 
excess may deplete the central nervous system neurones to such an 
extent as to greatly predispose to paresis, but is almost never an 
exciting cause, as has been thought. This disease, with locomotor 
ataxia, must be put down as being in 75 per cent of cases (more in 
our experience) due to syphilis. Krafft-Ebing gives 80 per cent 
as being specific; and when occurring in children Zappert makes 
362 



PAKESIS 



363 



the proportion of cases of paresis due to syphilis over 87 per cent. 
Sunstroke, exposure, injuries, and acute diseases are also exciting 
causes in the ininority of cases. But once having had syphilis 
associated with any other of the causes enumerated, such a one is 
very likely to develop paresis in from eight to fifteen years after 
the initial lesion. The disease occurs more frequently between the 
ages of twenty and forty, most usual about the thirtieth year. It 
is more frequent in married people, and is found oftener in city 
than country, for obvious reasons already inferred. 

Symptoms. — There are two stages: one of excitement or irri- 
tation, the other of dementia and paralysis. Substitution for the 
first stage may be in a prolonged period of melancholia or hypo- 
chondriasis. In other cases the dementia and bodily enfeeblement 
may go hand in hand from the first. The first type is the most 
common, although the opinion is growing that mental disturbance 
is becoming less in importance than is the initial physical weak- 
ness. Thus it is assumed that 
paresis is becoming much ' 
more a disease of the brain 
and cord and less a disease of 
the mind, the mental symp- 
toms being that of a progres- 
sive dementia from the in- 
cipiency of the process. 

Usual Type. — First stage: 
The patient shoAvs nu usual 
irritability of temper; he is 
annoyed by trifles, his fam- 
ily noting the marked change 
in disposition to the house- 
hold; also a lack of proper 
appreciation of business rela- 
tions. He becomes peevish, is 
easily fatigued, is exhausted 
without cause, and is unable 
to fix his attention for any 
length of time upon his af- 
fairs. He is apt to be ex- 
travagant or make some foolish error in judgment. This con- 
dition of irritability is followed by great exaltation. He becomes 




Fig. 79.— Paretic Dementia. Ordinary 
Type, Second Stage. (Philadelphia 
Hospital, Insane Department.) 



364 TREATISE OX XEEYOUS DISEASES 

happy, and possesses a feeling of ^^ well-being.'' He is effusive of 
speech, and jocose where he was formerly sober or reserved. He 
develops great ideas, as of money-making, and all by a conglomer- 
ate mass of ideas, such as by a meat-market and automobile es- 
tablishment combined. These delusions of grandeur (megalo- 
mania) are more or less periodic, and the period of exaltation 
often gives place to outbursts of violence, this latter being more 
pronounced if he has developed a transient dipsomania, which is 
not unusual. Within a few months the family usually solicit aid 
of the physician, and the patient is confined in an institution 
where he can do himself or others no harm. Often under this re- 
straining influence apparent remissions occur, and occasionally 
real remissions occur, as in a case of the writer's where ten years 
had elapsed since a staying of all symptoms of undoubted paresis 
has occurred, the man still holding the initial symptoms. 

Usually, however, after some months in a hospital the patient 
begins to show marked signs of dementia, memory becom.es worse, 
he misplaces objects, forgets recent matters, commits errors in 
figuring, cannot write coherently, or may make mistakes in spell- 
ing or elision of letters. The handwriting becomes wavering, the 
letters showing irregularities in the strokes. 

During the exaltation period physical signs develop which are 
characteristic. Besides the difficulty in writing, noted above, there 
is decided facial tremor, brought out the more when the patient is 
told to close his eyes and stretch the muscles of the face so as to 
show the teeth. Marked tremor of the tongue is present, much 
like that of acute alcoholism. Speech becomes thick; he stutters; 
it is very difficult to pronounce long words. These evidences of 
dysarthria are entirely cerebral in origin. The knee-jerks are usu- 
ally increased. The pupils are generally unequal; they are apt to 
react badly to light,^ and even sluggishly to accommodation. The 
fimdi oculi are normal. 

An early and decided weakness of the sexual function is found. 
The vesical sphincter may become paretic, allowing " dribbling " 
of urine. Appetite may be increased, manner of taking food glut- 
tonous. Vegetative organs remain normal until very late in the 

1 The true Argyll-Robertson pupil, recorded in the books, the writer has 
not found in twenty-five out of one hundred cases carefully examined. Irreg- 
ularity and iridoplegia he would beg to submit as being the most characteris- 
tic pupillary signs in paresis, 



PARESIS 365 

course of the disease. The patient often suffers from insomnia, 
or he may be subject to vertiginous, syncopal, or pseudo-apoplecti- 
forni attacks, in the latter of which he may fall over and be a suf- 
ferer from hemiplegia, lasting for a few days or even weeks. Epi- 
leptic convulsions may occur. In rare cases there is abolition of 
the knee-jerks and ataxic symptoms somewhat resembling the pa- 
retic stage of tabes. In such cases the general muscular power is 
much diminished, the patient being unable to do any sustained 
muscular work, as walking any distance. True apoplexy may 
occur. 

In the second stage the most striking sign is the gradual onset 
of dementia. The patient sleeps much in daytime and becomes 
more quiet. He is very forgetful now, may not at times even rec- 
ognise his friends, and, of course, takes little interest in outside 
affairs. He cannot speak of current events, forgets the day of the 
week, etc. He soils himself at meals, slobbers his liquids, and 
takes no interest in his personal appearance. He may be uncleanly 
at the toilet, and finally becomes as dependent as a small child. 
Later apoplectiform attacks occur with permanent hemiplegia, as 
noted above. He may now- gain flesh and have a very voracious 
appetite. In periods of excitement at this stage he may have 
delusions of persecution or slight delusions of grandeur. Tremor 
increases and speech becomes distinctly w^orse. The average dura- 
tion of the disease is about three years. Some may die wdthin a 
year, or remission may occur and the patient live in dementia 
fifteen years in rare cases. [A patient of mine imagined he gained 
untold w^ealth from day to day, although he did not name any 
specific sum. He then quickly became bedridden and helpless.] 

Dementing Type. — In this form there is a primary dementia, 
beginning wdthout any excitement. First there is lack of atten- 
tion to business, forgetfulness, and general incapacity for work. 
The patient makes mistakes in dates, in calculations; is good- 
natured to everybody about him, is passively happy. He may 
have no delusions of any sort. Somatic symptoms of tremor, fixed 
pupils, exaggerated reflexes, finally appear and become characteris- 
tic. The scanning speech may appear last of all in this type. 
There may be increase of phosphates in the urine, particularly 
showing during any excitable period. Excess of uric acid w^e have 
also found in these cases. Leucocytosis is generally present. The 
red blood-cells become qualitatively changed, there being a relative 



366 TREATISE OX XERVOUS DISEASES 

increase of the polynuclear cells, very much as shown in a btiidy 
with Dr. Xapoleon Boston ^ to exist in idiopathic epilepsy. 

Hypochondriacal Type. — In this form the symptoms begin with 
those of hypochondriasis and neurasthenia. The patient complains 
of a vague feeling of distress about the head, of hemicrania at 
times: also of pain in the back and limbs. One of my recent 
cases complained most distressingly of dull pain in the epigastrium, 
the tongue being constantly coated, and large amounts of indican 
were found in the urine. Yague sense of discomfort also occurs, 
which the patient at bis best (in the early morning) is still unable 
to describe. Frequentl}' these are treated for weeks as cases of 
neurasthenia, since at the start they scarcely show any physical 
or mental symptoms. But careful study of anamnesis will reveal 
in the history syphilitic infection, while a study of the physical 
signs will show the rigid pupils as perhaps the only clue to somatic 
failure. After a year or so mental unbalance appears, shown in 
suspicion, dementia, delusions of persecution, and the like. Occa- 
sional outbreaks of violence may occur, then all the typical signs — 
alteration of speech, tremor, etc. — will follow. 

Syphilitic Pseudo-Paresis. — In some cases of paresis symptoms 
of exudative syphilis introduce the disease. The patient has at 
first palsies of the eyes, or attacks of hemiplegia with intense head- 
ache, followed by convulsions. The specific exudate is found to 
either be pressing against the convexity or more usually against 
the base. Under proper treatment resolution of the granulomata 
occurs and the seizures or paralysis disappear, but it is now found 
he is emotional, is excitable, his memory is impaired, judgment is 
weakened; he has to live a quiet, inactive life, giving up his regu- 
lar employment or professional work. A pronounced dementia 
may not set in for eight or nine years in this class of cases. 

Alcoholic Pseudo-Paresis. — Those who have for a long time 
continuously indulged in alcohol or who liave been debauchees in 
abuse of alcohol may finally develop — usually do — a condition of 
mental weakness simulating paresis. I had a patient of emi- 
nently nervous temperament, but of good ancestry, who. follow- 
ing troubles in his family, drank, not so heavily, but periodically, 
to the production of mania a potu on several occasions only. This 
was followed by a typical form of pseudo-paresis due to acute 
alcoholic intoxication. 

^ Transactions of the College of Physicians of Philadelphia, April 1, 1903. 



PARESIS 367 

In these patients, there having beeii no syphilitic infection, 
there is no true paresis. Such patients are selfish, at times become 
bestial, while at all times they show feeble judgment ; the memory 
becomes a blank. There is a gradual loss of the moral sense. De- 
mentia progresses slowly, but these cases are usually carried off by 
some intercurrent disease. They never present the physical signs 
nor typical symptoms of true paresis. If alcohol is withheld they 
may live many years. 

Pathology. — Paresis is a parasyphilitic disease (90 per cent) 
due to degeneration of the cerebral neurones from the syphilitic 
toxines developed late in the luetic malady. There is first thicken- 
ing of blood-vessels due to periarteritis, endarteritis, and prolifera- 
tion into the perivascular tissue. It is in doubt whether the degen- 
eration of the nerve-cell is really secondary to the above changes; 
or is primary, as is the case in tabes. Most authorities cling to the 
latter view, which is probably the correct one. 

On examination, the brain shows thickening and vasculariza- 
tion of the dura mater. This membrane is generally partially 
adherent to the cranial bones. The brain mass itself has usually 
undergone atrophy, as shown by decrease of a few ounces in weight 
over the normal. There is also increase of cerebro-spinal fluid. 
The pia mater in the fore and mid regions of the brain is much 
congested. It and the arachnoid are much thickened. The latter 
is adherent to the brain throughout, and when torn away the cortex 
is found to be oedematous. 

Microscopic study reveals increase of the connective tissue and 
the neuroglia about the blood-vessels of the cortex, thickening of 
the interna and all the vascular coats to some degree, together with 
degeneration of nerve-cells at all ages. N"ot onty'the neurones of 
the gray cortex, but those of the medulla, are also involved in the 
fatty change. 

Lesions of the posterior and lateral columns of the cord may 
also be found in a third of the cases. Therefore locomotor ataxic 
symptoms will be found in 33-J per cent of cases of paresis. 
(A less number of cases of primary ataxia (4 per cent) will 
end in paresis — the third stage of ataxia. (See Tabes.) This is 
due to the fact that tabetics usually are carried off early by other 
disease.) 

Prognosis. — This is invariably unfavourable. The patient may 
often, however, be partially restored by the use of tonics, gen- 



368 TREATISE ON NERVOUS DISEASES 

eral remedial and hygienic measures, which includes with particu- 
larity the removal of the patient from all forms of excitement; 
also the enforcement of quietude. The use of specific medication 
in acute early developing cases after the luetic infection may also 
tend to stay the progress of the disease. Although the use of mer- 
curials and iodides will not cure or stay the advanced stage, I 
have seen in the early stage great good result from their use; in 
several cases apparent cures result. When the frank typical 
symptoms once develop, cure is impossible at the present stage of 
our art. Remissions and the milder type of the affection within 
the last decade have a more promising hope for greater accuracy 
in scientific treatment, awaiting only future development. 

Treatment. — In the early developing cases, as indicated, place 
the patient promptly on antisyphilitic treatment — K. I., gr.v, t. i. d., 
HgCl2, gr. ^ig, t. i. d., or even the use of inunctions of mercurial 
ointment, a dram daily. The patient should be kept absolutely 
under control by removing him to some hospital or institution 
for mental and physical quiet, with an abundance of fresh air and 
sunlight about him. Tonic measures, such as the use of the 
Brown-Sequard testicular mixture (in glycerine), I have seen do 
good in stimulating the patient and aiding metabolism generally. 
The use of the ductless glands, as thyreoid or adrenals, may also, 
by aiding nutrition and oxidation, be of service in staying the 
disease. Glycero-phosphate of lime, 10 grains three times a day, 
I have seen give much benefit. The Charcot douche, cold sponge 
daily, and light massage aid much in procuring better circulation. 
Bromides must be employed as periods of excitement indicate. 
Hyoscine hydrobromate, gf. -gV, hypodermically, is of great value 
in maniacal outbursts.- Chloral and morphia should be cautiously 
employed. 



APPENDIX 



DISOEDEES OF SLEEP 

Consideration of the physiology of sleep and waking has 
been studied in the forepart of this work (Chapter I^ pp. 42 
and 43). 

The symptomatic disorder^ insomnia, has also been treated at 
length in another place (p. 126). 

Sleep is that calm to the nervous system that supplies nerve 
energies for the workingman. There are many theories of the 
causation of sleep, the latest being that of retraction of the proto- 
plasm of the cortical neurones. This separating one from another 
cuts off the association of nerve impulses of the higher centres/ 
while those lower more physical or vegetative functions still are 
active. This beautiful mechanism is thus well illustrative of the 
possible gross mechanism of mind action.^ It at least permits 
of better conception of the ever mysterious phenomena of sleep. 
The causation of sleep is more universally, however, considered to 
be due to anaemia of the brain. This theory has its partial proof 
in the fact that the blood pressure is lowered during sleep, as shown 
by sphygmographic tracings. Self-developed catabolites may be 
the remote cause back of all others; these autochthonous poisons 
precipitating* the mechanical status of the cells found during sleep. 

Given a healthy mind in a healthy body, we have the highest 
type of man: mens conscia recti. So that the wear and tear of 
life is constantly balanced in part by periods of repose, particu- 
larly of sleep. There is never an absolute repose of mind or body, 
however, from birth to death. 

There is nothing so subtle or important as the study of the 
disorders of sleep. In the .first place, we must recall that there is 

' See the discharge theory suggested by Bechterew (Neurol. Centralbl., 1896, 
Nos. 2 and 3) ; also the studies of Forel, His, and Cajal abroad, and Dercum in 
this country (Functions of the Neurone, Jour, of N. and M. Dis., August, 1896). 
24 369 



370 TREATISE OIST NERVOUS DISEASES 

an individuality about tiie amount of sleep necessary as a restora- 
tive agent. Some nerve protoplasm requires more hours of sleep 
than another. 'Not is it the neurotic person that requires most. 
It is simply a matter of idiosyncrasy, which only can be judged 
by the history of any case. In proportion as sleep does service in 
resting the mind, do we have the only accurate index of the value 
of a given slumber; and yet, as some one has well said, a dreamless 
sleep probably does not occur. We should reason from this that 
fixing or a resetting of our thoughts during the time of peaceful, 
quiet sleep is one of its functions. Indeed, too, the mental impres- 
sions thus finally fixed during sleep are probably of the most en- 
during nature — the mainsprings of character; for consciousness 
brings its artificialities, while the various pitfalls of convention- 
ality are entirely done away with in sound sleep, and the best 
things of the mind remain afterward. It is but the demonstration 
of God's rule as set down by Darwin, " the survival of the fittest." 
It is a high province of the physician to bring about natural sleep. 

A. Wakeful Disorders of Sleep 

Insomnia may be said to be the most important disturbance of 
sleep. Its causes are legion : pain, lack or excess of exercise, 
toxaemias, excitement, or worriment. In the treatment of it no 
physician can be successful unless he seeks out the fundamental 
cause. 

Pain, if intractable, must be counteracted by a dose of mor- 
phine. Poisons should be eliminated. Exercise must be regulated 
to oxA^genate the blood properly; a happy medium for the indi- 
vidual case is to be sought. It is folly to advise long walks for the 
banker or a series of rigid calisthenics for an overworked lawyer or 
physician or student. This I have seen do almost irreparable dam- 
age in a neurasthenic man attending the regular gymnastic course 
in one of the leading universities of Xcav York State. Excite- 
ment must be ad minimum in the sufferer from insomnia. It is 
well also to arrange, for the several hours preceding " bedtime," 
especial mental and physical quietude. The room should be well 
ventilated in which the patient sleeps. It should be dry, prefer- 
ably in a room of northern exposure, since many are easily wak- 
ened, as by rays of the rising sun at daybreak. All extrinsic causes, 
such as noises, should be giiarded against. I have seen patients 



APPENDIX 371 

immediately improve by being taken to another room when some 
particular, though slight, noise, not thought of by the sufferer, 
was the cause of his awakening. 

General methods to employ are warm water bathing (temper- 
ature 112° F.), followed by a brisk rub with a Turkish towel; or 
light massage, especially stroking the forehead at the end of the 
treatment; or hot milk taken at the moment of retiring. Hyp- 
notism may be resorted to in the exceptional case where hysteria 
is the base of the trouble, but it is not a reliable agent, and is 
liable to abuse. 

Where high arterial brain pressure exists the cautious employ- 
ment of depressants, as aconitia, gr. -^q at bedtime, or several min- 
ims of tincture of aconite, I have seen of positive service. But any 
attempts to relieve vascular pressure by nitro-glycerine will aggra- 
vate the case, due to increasing the flow of blood to the surface, 
and therefore the meninges, thus causing irritation of the branches 
of the fifth nerve. 

So7nnam.hulism is sleep-walking, a state in which the patient 
acts his part of a dream. In this disorder the subject passes, 
more or less automatically, through various apparently natural 
phases of physical and organic life, without full mental inhibition 
existing as when the conscious mind controls him. Somnam- 
bulism is, to a degree, evidence of unrest, of inevitable wakeful- 
ness. I have a patient who walks about at night frequently, talks 
coherently the while to those who address her, but in the morn- 
ing she is exhausted and remembers nothing of the phenomena. 
Thus, too, it is with people who dream constantly. It is evidence 
that the physiological mechanism is out of kilter, so to speak, 
especially if the dream is something " horrible " or unpleasant. 
" Pleasant dreams " are, however, natural and not in any extent 
exhausting, because they are natural, and any natural event is a 
stimulation of metabolism without which latter mind action can- 
not be at its best. The proverbial saying that chronic invalids 
develop frequently the best mental and moral specimens of men 
and women is not borne out by the cold facts, as physicians so well 
know. They are good specimens in spite of their infirmity only. 
Disorders of digestion have much to do with both of the above 
states. One so disposed should be instructed to be very cautious 
about indiscretion in diet. An hypnotic given at bedtime, prefer- 
ably trional, grs. xv, or chloralamid, gr. xij, will aid to prevent 



372 . TREATISE ON NERVOUS DISEASES 

attacks of either. The hygienic care is, in other respects, the same 
as in simple essential insomnia, a most important matter. 

B. Somnolent Disorders of Sleep 

These are the disorders marked by an irresistible desire to 
sleep, and they are not so frequent as Class A, bnt' usually imply 
the same grave organic disease or incurable affection, where the 
underlying pathology is not as yet definitely determined, except 
in hysteria, which may simulate any malady. 

Ecstasy, catalepsy, and trance are accidental somnolent states 
occurring in hysteria. Ecstasy is a more or less transient emo- 
tional state when the patient is transfixed, as it were, in self-con- 
templation. When there is general muscular rigidity associated 
for some period of time, catalepsy exists. A trance is a passive 
condition of quiet somnolence in which the patient lies motionless 
with all function at the lowest ebb. Respiration and pulse may be 
almost imperceptible. 

The treatment of these three conditions will be that of the 
management of a general hysterical state. It should be mentioned 
that some complex treatment, such as hypnotism, or a long series 
of regulated exercises in deep breathing, the mental and hydro- 
therapeutic value of a cold shower-bath, together with forced feed- 
ing to the constitutional limit, singly or combined, will offer the 
best rewards in cure to the caretaking physician. 

Sleeping sickness, as recently described by Manton and Mott as 
due to filaria and occurring in certain natives of Africa, is a 
clinical syndrome in which somnolence appears in intervals grad- 
ually increasing until the patient sleeps steadily for many hours. 
At first the patient can be aroused sufficiently to take food, and 
finally awakened with extreme difficulty. 

In two cases studied by Mott ^ a chronic infused leptomenin- 
gitis and encephalomyelitis were found, but no infectious organ- 
ism. In studying the blood ^ for another purpose with Dr. 
Napoleon Boston, this observer discovered in a rat's blood an 



1 British Medical Journal, December, 1899. 

2 The Blood in Epilepsy: Experiments on Animals. Transactions of the 
Physicians of the College of Philadelphia, March, 1903. American Journal of 
Insanity, January, 1904. 



APPENDIX 



373 



actively motile micro-organism similar to the one described by 
Manton very recently as a probable cause of sleeping sickness. 
Upon a warm slide^ with the lower power of the microscope, the 
organisms could be readily seen pushing the corpuscles about. The 
organism has been designated Tryfanosomos CasteUani from its 
discoverer. 

If this organism is the cause of this disease some form of 
immunization or prophylaxis seems to be the only possible hope 
for cure in the future. 

Narcolepsy is a condition in which the patient repeatedly goes 
to sleep in the day. It is a marked form of epilepsy and requires 
the same treatment (see Epilepsy). 

ADDITIONAL FIGURES 




Fig. 80.— Spastic and Athetoid- Movements in Face, Tongue, and Pharyn- 
geal Muscles. Case of Cerebral Spastic Paralysis. (Philadelphia Hos- 
pital.) 



3U TEEATISE 0^ NERVOUS DISEASES 




Fig. 81. — Attitude in a Case of General Athetosis in Cerebral Palsy of 
Childhood. (Philadelphia Hospital.) 



APPENDIX 



376 




Fig. 82.— Secondary Contractions of Face, Arm, Hand, Foot, and Leg in 
Case of Chronic Left Hemiplegia. (Philadelphia Hospital.) 



376 



THEATISE OX XERVOUS DISEASES 




Fig. 83— Tumour (Endothelioma). Inner Surface Cerebral Dura, (Museum 

of Philadelphia Hospital.) 



APrENDlX 



377 




24^ 



3?8 



TEEATISE OX XEPiVOUS DISEASES 




APPEXDIX 



379 



Triceps (long head) 

Triceps (internal head) 
Ulnar 



Flexor carpi ulnaris 
Flexor profundus digitorum 



Flexor sublimis digitorum 
(H and IH). 



Flexor sublimis digitorum 
'land IV). 

Ulnar. 

Palmaris brevis. 

Abductor minimi digiti. 

Flexor brevis minimi digiti. 

Opponens minimi digiti. 

Lumbricales. 




eltoid (anterior 
half). 



Musculo-cutaneous 
Biceps. 
Brachialis anticus- 



Supinator longus. 
Pronator radii teres. 
Flexor carpi radialis. 



Flexor sublimis digitorum. 

Flexor longus pollicis. 
Median. 

Abductor pollicis. 
Opponens pollicis. 
Flexor brevis pollicis. 
Adductor pollicis. 



Fig. 86.— Showing Motor Points. (Shoulder an.l Arm.) Anterior Aspect. 



380 



TEEATISE OX XERYOrS DISEASES 



Deltoid (posterior half). ■ 



Radial {musculo-spiral) 
Brachialis anticus. 



Supinator longus. 
Extensor carpi radialis longior. 
Extensor carpi radialis brevior. _ 



Extensor communis digitorum. 

Extensor indicis 

Extensor ossis metacarpi pollicis 
Extensor primi internodii pollicis 



Dorsal interossei, I and II. -. 




Triceps (long head). 



Triceps (external head). 



Extensor carpi ulnaris. 
Supinator brevis. 

Extensor minimi digiti. 
Extensor indicis. 



Extensor secundi internodii 
polUcis. 



Abductor minimi digiti. 



/ Dorsal interossei, 
/ m and IV. 



Fig. 87.— Showing Motor Points. (Shoulder and Arm.) Posterior Aspect. 



APPENDIX 



381 



Tibialis anticus. 
Extensor longus digitorum. 



Peroneus brevis. 



Extensor proprius pollicis, 



Dorsal interossei. 




Peroneal. 



Gastrocnemius (external). 
Peroneus longus. 



Soleus. 



Flexor loDgus hallucis. 



Extensor brevis digitorum 
Abductor minimi digiti. 



Fig. 88.— Showt>'G Motor PorsTS. (Leg.) 



382 



TREATISE O:^ XERVOUS DISEASES 



LESION CAUSING 
MONOPLEGIA OF LEG 



ORDINARY HEMIPLEGIA, 
PARALYSIS OF SIDE 
OPPOSITE TO LESION. 



HEMIPLEGIA OF OPPO- 
SITE SIDE, OCULO- 
MOTOR PARALYSIS OF 
SAME SIDE. 



HEMIPLEGIA OF OPPO- 
SITE SIDE, PARALYSIS 
OF FACE AND EXTER- 
NAL RECTUS ON SAME 
SIDE, 



UPPER MOTOR PATH =a RED. 
LESIONS OF THIS PATH 
CAUSE SPASTIC PARALYSIS. 



LOWER MOTOR PATH = BLUE 
LESIONS OF THIS PATH 
CAUSE FLACCID PARALYSIS. 



ORDINARY 
HEMIPLEGIA, 




HEMIPLEGIA, ARM 
MORE THAN LEG. 



HEMIPLEGIA 
WITH HEMIATHE 
TOSIS AND HEM! 
CHOREA. 



HEMIPLEGIA, LEG 
MORE THAN ARM, 
WITH HEMIANAES- 
THESIA, HEMIOPIA, 
AND DISTURBAN- 
ES OF HEARING, 
TASTE ? AND 
SMELL.? 




ERIOR 
EXTREMITY 
OF CAPSU LE. 

.sig-rfgN Tfp^ INTERNAL CAP SULE. 

III N. OCULOMOTOR. 

IV N. PATHETICUS. 

V N, TRIGEMINUS. 

VI N. ABDUCENS.. 

VII N, FACIAL- 



IX N. GLOSSOPHARYNGEAL! 

X N. PNEUMOGASTR-IC. 

XI N. SPINAL ACCESSORY. 



Xll N, HYPOGLOSSAL. 



LESION INVOLVING 
ANTERIOR HORN OR 
ROOT. FLACCID PAR- 
ALYSIS OF MUSCLES 
AT SITE OF LESION. 



TRANSVERSE LESION 
OF CORD. FLACCID 
PARALYSIS OF MUSC- 
LES LOCALIZED AT 
LEVEL OF LESION. 
SPASTIC PARALYSIS 
OF MUSCLES BELOW 
LESION, 



Fig. 89.— Showing the Effects of Various Lesions of the Motor Path in the Brain 
AND Spinal Cord. The Upper Right-hand Sketch shows the Variations in 
Symptoms caused bt a Difference in the Antebo - posterior Position of the 
Lesions in the Internal Capsule. 



APPENDIX 



383 




CTIIl 



Fig. 90.— Diagram of Skin Areas corresponding to the Different Spinal 
Segments. Anterior Aspect. (Combined from Head's Diagrams by Osier.) 



384 TREATISE OX NERVOUS DISEASES 



TII 




YII 



Fig. 91.— Diagram op Skin Areas corresponding to the Different Spinal 
Segments. Posterior Aspect. (Combined from Head's Diagrams by Osier.) 



APPENDIX 



385 



Tables 

The difference between multiple neuritis and poliomyelitis is 
well shown in the following modification of the summary by 
Starr : 



Acute poliomyelitis 
Sudden onset, with fever and de- 
velopment of paralysis in all the limbs, 
followed in from three to five days by 
subsidence of paralysis, which remains 
in a few muscles of one limb; or, if 
two are affected, the paralysis is rare- 
ly symmetrical. If the onset is sub- 
acute, four weeks is the duration of 
onset. The muscles are not tender. 
Sensory symptoms are rare, and, when 
present, soon subside. 



Multiple neuritis 
Fatigue for some weeks ; then sud- 
den onset and progress for two weeks 
with or without fever. Legs usually 
first affected, then arms, then body. 
The paralysis has no tendency to 
subside for some time (months). 
The limbs are affected symmetrically. 
Usually there is tenderness of the 
nerve-trunks and affected muscles, 
and pain, with areas of anaesthesia. 



GowERs's Table of Laryistgeal Paralysis 



Symptoms 

No voice ; no cough; 
stridor only on deep 
inspiration. 

Voice low pitched and 
hoarse; no cough; stri- 
dor absent or slight on 
deep breathing. 



Voice little changed; 
cough normal; inspi- 
ration difficult and 
long, with loud stridor. 

Symptoms inconclusive ; 
little affection of voice 
or cough. 

No voice ; perfect cough ; 
no stridor nor dysp- 
noea. 



Signs 

Both cords moderately 
abducted and motion- 
less. 

One cord moderately ab- 
ducted and motionless, 
the other moving free- 
ly, and even beyond 
the middle line in pho- 
nation. 

Both cords near together, 
and during inspiration 
not separated, but even 
drawn nearer together. 

One cord near the mid- 
dle line not moving 
during inspiration, the 
other normal. 

Cords normal in position 
and moing normally 
in respiration , but not 
brought together on an 
attempt at phonation. 



Lesion 

Total bilateral palsy. 

Total unilateral palsy. 



Total abductor palsy. 



Unilateral abductor 
palsy. 



Abductor palsy. 



25 



386 



TREATISE ON NEEVOUS DISEASES 



The following table from Sachs shows the lesions most likely 
to be present, according to the time of onset in Cerebral Palsies : 



Groups. 



Morbid Lesion. 



f Paralysis of intra- 
Diaplegia j uterine onset. 

and ^ 

paraplegia j 

L Birth palsies. 



„ . 1 • ( Acute (acquire 
Hemiplegia I ^^^^.^^i 



d) 



Large cerebral defects; porencephaly. De- 
fective development of pyramidal tracts. 
Agenesis corticalis (highest nerve-elements 
involved). 

Meningeal haemorrhage, rarely intracerebral 
haemorrhage. Later conditions, meningo- 
encephalitis chronica, sclerosis, cysts, par- 
tial atrophies. 

Haemorrhage, meningeal and rarely intra- 
cerebral; thrombosis, from syphilitic 
endarteritis and in marantic conditions ; 
embolism. Later conditions, atrophy, 
cysts, and sclerosis (diffuse and lobar). 

Meningitis chronica. 

Hydrocephalus (seldom the sole cause), 
primary encephalitis, polio-encephalitis 
acuta (Striimpell). 



Differential Points of the Two Forms op 
' Ataxia " 



Family 



(I) Friedreich's Form 

1. Occurs before puberty. 

2. Choreiform movements seen affect- 

ing head, arm, and trunk. 

3. Optic atrophy exceptional. 

4. Tendon reflexes diminished or 

abolished. 

5. Club-foot and scoliosis common. 



(11) Marie's Form 

1. Occurs after puberty. 

2. Choreiform movements are very 

pronounced. 

3. Optic atrophy is common. 

4. Increased reflexes and clonus fre- 

quent. 

5. Club-foot and scoliosis are excep- 

tional. 



FORMULARY 



For anagmia in neurasthenia. 

5 Pil.Blaudgr.v]^"'"^"'!''^^ , .. .. 

° ( Potass, carbonat aa gr. i]ss. 

Sig. : One or two pills ten minutes after meals. 

Xeurasthenia (essential). 

^ Sod. brom. / __ .. 

Ammon. brom. [ ' ''* 

Aquae q. s. ad 3 iij. 

M. et sig. : Teaspoonful every three hours until head symp- 
toms relieved. 

Xeurasthenia (insomnia of). 

^ Trional 3 ij. 

M. et ft. chart Xo. x. 

Sig. : One at nine o'clock in hot milk. 

Xeurasthenia (sexual). 
^ Ferri valerianat j 

Zinci valerianat v aa gr. xxiv. 

Quin. valerianat ) 
M. et ft. pil. Xo. xxiv. 
Sig. : One after meals. 

Also neurasthenia (sexualj with irritable bladder. 

^ Potass, citratis 3 iij. 

Essence pepsini fl. § 3. 

Aquae cinnamonii 5 iij. 

M. et sig. : Teaspoonful every three hours. 

For nervous cough. 

^ Ammon. chloridi 3 JS3. 

Sod. bromidi 3 iij. 

Tr. opii. camph fl. f ss. 

Aq. menth. pip q. s. ad fl. ? iij. 

M. et sig. : Teaspoonful every three or four hours. 

387 



388 TREATISE OX XERYOUS DISEASES 

For dyspepsia (nervous) with gastrectasia. 

^ Tr. nucis vom fl. 3 j. 

Sodii bromidi 3 vj. 

Tr. aurantii fl- 3 j. 

Tr. gent, comp q. s. ad fl. § iij. 

M. et sig. : Teaspoonful a half hour before meals. 
Also 

R Ext. chiratta ) ._ . 

-^ , , . y aa ffr. xxiv. 

Ext. gentian ) ° 

M. et ft. capsnle Xo. xxiy. 

Sig. : One a half hour before meals. 

Also 

I^ Tr. nncis vom fl. 3 iv. 

Sod. bicarb 3 jss. 

Inf. gent, comp q. s. ad. fl. | iij. 

M. et sig. : Teaspoonful before meals. 

For nervous syphilis. 

5t Hydrarg. chlor. corrosive g^** j • 

Potass, iodidi fl. 3 ij. 

Aquae cinnamonii q. s. ad fl. | iij. 

M. et sig. : Teaspoonful after meals. 

!N"ervous syphilis (tonic in). 

^ Tr. nucis vom 3 ij. 

Elix. calisayge q. s. ad § iij. 

M. et sig. : Dessertspoonful every three hours. 

For hysteria. 

5 Pil. asafoetida > gr. iij. 

Sig. : One three or four times a day. 

Hysteria and anaemia. 

r Ext. sumbul gr. j, 

T5 ' ., , T ! Ferri sulph. exsic gr. j. 

^ Pil. sumbul comp. <,.,.-, .. 

^ Asafoetida gr. ij. 

I Acid, arseniosi S^- ^' 

M. et ft. pil. 

Sig. : One three or four times a day. 



FOEMULARY 389 

Headache (simple). 

]^ Acetanilid gr- ij. 

Camphor monobrom gr. ss. 

Caffeine citratis gr. ss. 

M. et ft. pil. Xo. i. 

Sig. : One pill every three hours until four doses if required. 

Headache (alcoholism). 

R Tr. nucis vom. ) _ _ n ., . 

^ . . y aa n. 3 1. 

Tr. caprici j *" 

Sod. bromidi 3 ss. 

Tr. gent, comp q. s. ad fl. § iij. 

M. et sig. : Teaspoonful every three hours. 

For headache (la grippe). 

I^ Salol ) " -K ' 

Phenacetine ) 
M. et ft. cap. Xo. xii. 
. Sig. : One capsule every two or three hours for three doses. 

For headache (cerebral congestion and uricacidaemia). 

^ Sod. salicylat 3 iij. 

Codeine sulph gr. v. 

Elix. calisayae A- S ]• 

Aquae q. s. ad fl. | iij. 

M. et sig. : Teaspoonful every four hours. 

For mental depression (bilious temperament). 

^ Acid, nitrohydrochlor. dil fl. 3 ijss. 

Tr. nucis vom fl. 3 iij. 

Tr. aurantii q. s. 

Tr. gent, comp q. s. ad fl. | vj. 

M. et sig. : Teaspoonful a half hour before meals. 

For paroBsthesia. 

^ Ext. cascara sagrada fld fl- 1 j« 

Ext. ergot fld § ij. 

M. et sig. : Teaspoonful twice daily. 



For Stokes-Adams syndrome. 

1^ Nitroglycerine gr. 

M. et ft. pil. 

Sig. : One once or twice daily. 



ToTT* 



390 TREATISE OiV NEliVOUS DISEASES 



Stomach (irritability and acidity). 

1^ Sod. chlor '. . . 3 ij. 

Sod. phos 3 iv. 

Sod. sulph 3 X. 

M. et sig. : Teaspoonful in seltzer twice daily an hour before 
eating. 

General tonic in simple neurasthenia. 

3 Strych. sulph gr. yj^* 

Ferri sulph gr. f • 

Quin. snlph gi*- j- 

M. et ft. elixir q. s. ad fl. 3 j. 

Sig. : Teaspoonful after meals. 



INDEX 



Acromegaly, symptoms, 331. 

diagnosis, 331. 

patliology, 331. 

prognosis, 333. 
Action, reflex, 25. 
Adiposis dolorosa, 324. 

diagnosis, 325. 

patliology, 325. 

prognosis, 325. 

treatment, 325. 
Adjunct medication, 109. 
^sthesiometer, 65. 
^sthesodic, 26. 
Agenesis, 226. 
Ageusia, 73. 
Agraphia, 189. 
Ainhum, 330. 
Alcohol, 78. 

Alcoholic insanity, 358. 
Alcoholism (see Neuritis), 356. 

diagnosis, 355. 

drug intoxication, 354. 
symptoms, 354. 

pathology of chronic forms of, 356. 

prognosis, 355. 

prognosis of chronic forms, 356. 

symptoms, 355 

treatment, 355. 

treatment of chronic forms of, 356. 
Alexia, 192. 
Algesia, 56. 
Algometer, 68. 
Amaurosis, 70. 
Amblyopia, 70, 192.- 
Amblyopic tabes, 229. 
Amemia, 191. 

Amnesia, articulative, 193. 
Ampere, 92. 
Amyelia, 225. 
Analgesia, 66. 
Anaemia, 25. 
Anatomy, 1. 
Anelectrotonus, 93. 
Anencephaly, 196. 
Ankle clonus, 57. 
Anosmia, 72, 125. 
Anterior commissure, 7. 
Anterior poliomyelitis acuta, 255. 

diagnosis, 256. 



Anterior poliomyelitis acuta, pathol- 
ogy, 255. 

prognosis, 256. 

treatment, 256. 
Anterior pyramid, 16. 
Antifebrine, 360. 
Antipyrine, 360. 
Aphasia, examination for, 194. 

receptive, 191. 

sensory, 191. 
Aphasia, motor, 190. 

ataxic, 191. 

auditory, 191. 

visual, 191. 
Aphemia, 189. 
Apoplexy, 198-200. 

cause, 199. 

cerebral haemorrhage, 198. 

chronic state of, 202. 

coma in, 202. 

diagnosis, 205. 

embolic, 202-205. 

hyperpyrexia in, 201. 

in cardiac disease, 207. 

nursing, 205. 

pathology, 204. 

prognosis, 205. 

signs of attack, 200. 

treatment, 205. 
Appendix, 369. 
Apraxia, 189, 191. 
Arachnoid, 22. 
Arbor vitae, 20. 
Argyll-Robertson pupil, 60, 72, 227. 

in tabes, 231. 
Arthritic deformans, 340. 
definition, chronic, 337. 
diagnosis, 337. 
A.rthropathy in tabes, 229. 
Articulative amnaesia, 193. 

ataxia, 190, 
Artificial salt bath, 84. 
Ascending degeneration, 9. 
Asteriognosis, 58-185. 
Asynergia verbalis, 190. 
Ataxia, paralytic stage, 229. 

amblyopic stage, 229. 
Ataxic gait, 63. 
Athetosis, 68. 

391 



392 



TREATISE OX JSEKVOUS DISEASES 



Axioms, 98. 
Axis cj'linder, 4. 
Axone, 2. 



Beri-beri, 141. 
Biceps jerli, 59. 
Bilious temperament, 64. 
Bipolar cells, 2. 
Blindness, 37. 
Blood-vessels, 45. 
Blood-vessels in brain, 45. 
Brain, malformation of, 196. 
capsule of, 19. 
compression, 195. 
disease, symptomatology of, 195. 
irritative symptoms of, 195. 
tumour, 209. 
diagnosis, 211. 
localization, 210. 
pathology, 211. 
prognosis, 212. 
symptoms of, 210. 
treatment, 212. 
weight "of, 197. 
Brachial neuritis, 161. 
prognosis, 162. 
treatment, 162. 
Brachial plexus, injury of, 161. 
Brown-Sequard, 25, 55. 

paralysis, 5. 
Bulb, 188. 

Burdach column, 13. 
nuclei of, 18. 



Caisson disease, 217. 

pathology, 217. 

prognosis, 217. 

symptoms, 217. 

treatment, 218. 
Canal, double central, 226. 
Capsule of brain, 19. 

function of, 38. 
Catalepsy, 105. 
Cataphoresis, 93. 
Cathelectrotouus, 94. 
Cauda equina, 5. 

compression of, 241. 

diagnosis of disease of, 241. 

disease of, 241. 

irritation. 241. 

symptomatology of disease of, 
241. 

symptom of disease of, 241. 
Causalgia. 65. 
Cause of sleep, 43. 
Central canal, 7. 



Centre, primary optic, 187. 
automatic, 34. 
cardiac accelerating, 35. 
cardiac inhibitory, 35. 
detrusor, 37. 
inductive, 30. 
thermogenic, 38. 
Centres in medulla, 17. 
of consciousness, 41. 
Centrum, 186. 
Cerebellar ataxia, 240. 
pathology, 240. 
symptoms, 240. 
tottering, 33. 
treatment, 240. 
Cerebellum, 19. 
Cerebral hemisphere, 39. 
functions of, 39. 
localization, 183. 
neoplasm, 209. 
peduncles, functions of, 36. 
varieties of, 209. 
Cerebrum, 20. 
Charcot's artery, 28. 
douche, 84. 
joint, 230. 
Chemical stimuli, 26, 29. 
Cholesterin, 47. 
Chorea, 278. 

definition of, 278. 
paralytic symptoms, 278, 279. 
Chorea, 284. 

minor (see Sydenham's Disease 

and St, Vitus's Dance), 278. 
prognosis, 280-282. 
symptoms of, 280-282. 
Circulatory disturbances, 121. 
Clarke, column of, 9. 
Claw-hand, 213. 
diagnosis, 213. 
prognosis, 213. 
treatment, 215. 
Climatology in tabes, 233. 
in nervous diseases, 112. 
Coal-tar product into'xicaliou, 233. 
diagnosis, 360. 
prognosis, 360. 
symptoms, 360. 
treatment, 360. 
Cocaine habit, 359. 
prognosis, 359. 
treatment, 359-360. 
Cold packs, 84. 
Coma. 54. 

Combined sclerosis, 260. 
diagnosis, 262. 
prognosis, 262. • 
symptoms, 260. 
treatment, 260. 
types, 260. 



INDEX 



393 



Combined sclerosis, tj-pes of Putmim- 

Leichtheim-Dana, 2G0. 
Comma tract, 14. 
Conjugate deviation of the eyes. 40, 

68, 202. 
Contractures, 66. 
Convalescence of nervous functional 

diseases, 107. 
Convolutions, 21. 

ascending frontal, 185. 

central, 183. 

parietal, 185. 

tirst frontal, 185. 

second frontal, 185. 

Convulsions, clonic, 53. 

tonic, 53, 66. 
Convulsive (Tic), 268, 288. 
diagnosis, 287. 
prognosis, 287. 
Co-ordinating centres, 33. 
Corpora quadrigemina, 22, 187= 

functions of, 16, 30. 
Corpus callosum, 186. 
striatum, 22, 186. 

functions of, 367. 
dentatum, 20. 
Cretinism, 61. 
Crossed pyramidal tracts, 13. 

hemiplegia, 28. 
Crus cerebri, 187. 
Cyclopia. 197. 



Dance, 86. 
Deafness, 72. 

psychic, 193. 
Decubitus, 64. 
Deep reflexes, 57, 73. 
Degeneration, 15, 49. 
Degenerative reaction, 94, 97. 
Dementia paralyticus, 362. 
Dendron, 2. 
Dentate nucleus, 16. 
Dermatosis gangrenosa nervosa, 327. 
pathogenesis, 328. 
prognosis, 328. 
Descending degeneration, 9. 
Detrusor centre. 36. 
Diagnosis, 93. 
Diet, 79, 106. 

Diffuse and focal diseases of the 
spinal cord, 243. 
disease of brain and spinal cord, 

267. 
disease of motor neurons of cord, 
234. 
spinal-cord functions, 240. 
Diplegia. 66. 

Direct cerebellar tract, 14. 
pyramidal tract, 11, 14. 



Disassociation of sensation, 67. 
Diseases of brain, 195. 
membranes, 194. 
spinal cord, 221. 
Diver's disease, 217. 
Dizziness, 113. 
Drip sheet, 85. 
Drugs, 24. 
Dura mater, 22. 
Dyslexia, 194. 
Dyssesthesia, 65. 

Elbow-jerk, 59. 
Eledlrical irritability, 93. 
Electricity, faradic. 101. 

Franklin, 104. 

galvanic, 31. 

generation of, 97. 

in tabes, 233. 

sinusoidal, 100. 

static, 104. 
Electrolysis, 92. 
Electro-motor force, 98. 
Electrotonus, 93. 
Embolism, 200. 
Encephalitis, acute symptoms of, 207= 

causes of, 207. 

chronic, 208. 

diagnosis, 208. 

pathology, 207. 

prognosis. 207. 

symptoms, 208. 

treatment, 208. 

varieties of, 207. 
Encephalocele, 96. 
Erb, electrical reaction of, 161. 
Erb's symptoms, 357. 
Erythromelalgia, 76-142. 

histological examination, 142. 
Exercise in nervous diseases, 80. 

Facial angle, 41. 
palsy, 129. 

diagnosis, 326. 

galvanism in, 131. 

hemiatrophy, 326. 

hemiatrophy, 326. 

intracranial, 129. 

intraosseous, 129. 

pathology, 326. 

potassium iodide. 131. 

strychnine in. 131. 

treatment, 130. 
Family ataxia, 138. 

periodical paralysis, 343. 

symptomatology of, 344. 
Faradic electricity, 100-101. 

brush. 104. 
Fasciculus of Tuerck, 11. 
Fechner's law, 43. 



394 



TREATISE OX XERVOUS DISEASES 



Festination, (53. 
Filum terminale, 5. 
Fissure of Rolando, 39. 
location of, 39. 
median. 7. 
Fissures of cerebellum, 39. 
Flechsig, 9, 11, 21. 
Franklin electricity, 104. 
Frazier (C. H.), 340. 
Friction, 86. 

Friedrich's ataxia (see Heeeditaky 
Ataxia), 238. 
diagnosis, 239. 

prognosis, 238. * 

symptoms, 238. 
treatment, 239-240. 
Frontal convolutions. 18-5. 
Forced movements, 37. 
Formatio reticularis, 16. 
Forms of disease. 49. 
Funiculi, 89. 

cuneatus, 16. 17. 
gracilis, 5. 

medulla oblongata, 34. 
Rolando, 17. 

Gait, 61, 62. 
Galton's whistle, 72. 
Galvanic current, 31. 
Gangrene, 29. 
Gastralgia, 120. 

General functional nerve disease, 277. 
paralysis of insane, 362. 
paresis, 362. 
Generally nervous, 79. 
Geniculate bodies, 22. 
Genito-urinary, 60. 
Gerlacli's bodies. 
Giddiness. 113. 

Giles de la Tourette's disease, 286. 
Girdle pain, 170, 227. 

sensation. 227. 
Glandular defects, 49. 
Glassbl'ower's disease. .319. 

aetiology, 319. 

definition, 319. 

pathology, 319. 
Glia cells, 46. 
Gliosis. .51. 
Glosso-labio-pharyngeal palsy, 257. 

acute form, 2.58. 

asthenic form. 258. 

chronic, 258. 

pathology, 257. 

prognosis, 258. 

pseudo form. 257. 

symptoms, 257. 

treatment, 258. 
Goll, 14. 
Gowers, 11. 



Grasp, 63. 

Graves's disease, electricity iu, 97. 
Guide to note-taking, 55. 
Gyrus fornicatus, 211. 
tumour in, 211. 

Habit chorea, 283. 
diagnosis, 284. 
pathology, 284, 
prognosis, 283. 
symptoms, 283. 
treatment, 284. 
Hsematoma dura, 175. 
diagnosis, 175. 
prognosis, 175. 
symptoms, 175. 
treatment, 176. 
Hsematomyelia, 245-247. 
diagnosis, 246. 
pathology, 246. 
prognosis, 247. 
symptoms, 246. 
treatment. 247. 
Hsemorrhage in substance of cord, 
245. 
aetiology, 245. 
Hair, removal of, 97. 
Hallucinations, 45. 
Hammer-toe, 166. 
Hammond. Dr., as. 
Headache. 120. 
causes of. 121. 
varieties of. 121. 
Hearing. 72. 

Heart, neuralgia of, 120. 
Heat exhaustion, 340. 

prognosis, 341. 
Hemianopsia. 55, 69, 70, 192. 
Hemiopia. 70. 

Hemiplegia. 15. 39. 196, 204. 
gait in, 202. 
in neuritis, 204. 
secondary contraction in. 204. 
sweating in, 195. 
Hereditary ataxia (see Fkeidrich's 

Ataxia), 2.38. 
Hereditary spastic paralysis, 238. 
chorea. 284. 286. 
diagnosis. 285. 
duration, 285. 
Hernia, 197. 

Herpes zoster in Pott's disease, 163. 
Heteropia. 225. 
High flushing of colon, 110. 
Hippocampal convolution, 18. 
I Hippus, 71. 
Hoffman symptoms, 357. 
Holtzapple. Dr.. 343. 
Huntingdon's disease (see Hereditary 
Thobea). 284. 



INDEX 



395 



Hydreucephalocele, 196-198. 
Hs'drocephaiic cry, 178. 
Hydrocephalus, 177, 
acquired forms, 180. 
acute symptoms, 177. 
chronic, 179. 
external, 177. 
internal, 177. 
pathology, 176. 
prognosis, 178. 
symptoms, 179. 
treatment, 179. 
Hydromvelia, 212. 
symptoms, 213. 
Hydrophobia (see Rabies), 346-347. 
Hydrorhachis interna, 223. 
Hydrotherapeutics in nervous dis- 
eases, 81. 
Hj-giene, 78. 
Hypersemia, 49. 
Hypersesthesia, 53, 65. 
Hyperageusia, 73. 
Hyperosmia, 72, 125. 
Hyperostosis cranii (cephalomegaly), 
322-323. 
diagnosis, 323. 
pathology, 324. 
symptoms, 323-324. 
Hypertrophic pulmonary arthropathy, 
334. 
pathology, 334. 
treatment, 334. 
Hypnotics, 43. 
Hypnotism, 104, 105. 

in tabes, 229. 
Hyposesthesia, .53, 65. 
Hysteria, 302. 
8etiology, 302. 
definition, 302. 
diagnosis, 304. 

Gowers' differential table, 302-303. 
grand attacks in, 304. 
hypnotics in, 305. 
passionate attitudes in, 304. 
prognosis, 305. 
psycho-sensory, .302. 
segmental anaesthesia, 303. 
catalepsy, 304. 
motor symptoms, 304. 
paroxysmal stage, 304. 
stigmata, 303. 

divisions and symptoms, 308. 
pathology, 312. 
rigidity of back, 309. 
tender spots, 309. 
traumatic or railway spine, 308. 
treatment, 312. 
symptoms, 302. 
treatment, 305. 
Hysterical or hystogenic zones, 303. 



Ideation, 45, 193. 

Idiopathic muscular atrophy, 252. 

juvenile, 254. 

neurotic, 254. 

pathology, 254. 

treatment, 255. 
Illusion, 45. 

Incisures Lantermann, 4. 
Inductive centres, 30. 
Inflammation, 24, 50. 
Inhibition, 24. 
Insomnia and causes, 115. 
pathology, 116. 
treatment, 116. 
Interfascicular arcades, 46. 
Interpeduncular space, 119. 
Irritability of nerves, 29. 
Irritable spine, 221. 
Irritative lesions, 184. 
Isolation in nervous diseases, 106. 

Jacksonian cerebral epilepsy, 40. 
Jacobson's nerve, 132. 
Jaw-jerk, 59. 
Jumper's disease, 287. 
Jumping disease, 288. 

diagnosis, 288. 

pathology, 288. 

prognosis, 288. 

saltatory spasm, 288. 

treatment, 288. 



Kakke, 142. 
Kernig's sign, 173. 
Krause, 47. 



Labile current, 99. 
Landry's paralysis, 218. 
diagnosis, 219. 
pathology, 219. 
prognosis, 219. 
treatment, 219. 
Lateral column, 11. 

fillet, 18. 
Lantermann's incisure, 5. * 
Lead, mercury, and arsenic poisoning, 

357-358. 
Lecithin, 33. 

Leptomeningitis, 171, 212, 215. 
cerebral, 177. 
prognosis, 177. 
symptoms, 177. 
treatment, 177. 
symptoms, 215. 
Lesions, destructive, 184. 

in diseases of cauda equina, 242. 
irritative, 184. 
of lower end of cord, 241. 



396 



TREATISE OTs NERVOUS DISEASES 



Lesions of periplieral uerves, 242. 
Lethargy in hypnotism, 105. 
Lissauer's tract, 15. 
Localization, ascending frontal, 184. 
parietal, 185. 

central convolutions, 185. 

cerebral, 183. 

corpus callosum, 186. 

cuneus, 185. 

frontal convolutions, 185. 

internal capsule, 187. 

occipital, 183. 

precentral lobe, 185. 

superior parietal lobe, 183. 

temporal lobe, 183. 

visual, 191. 
Lockjaw, 347. 

aetiology, 347. 

symptomatology, 347. 

treatment, 347. 
Luetic infection, 78. 
Lumbago, 162. 
Lymphatic temperament, 63, 



Malformations, 49. 

of brain, 196. 

of spinal cord, 221. 
Marie, types of family ataxia, 238. 
Martinotti, cells of, 21. 
Massage, 85. 

contraindications, 89. 
Mattson's thermometer, 77. 
Mechanical stimuli, 29. 
Medication, 109. 
Medulla oblongata, 15, 188. 

reflex action, 34. 
Megrim, 121. 
Meningitis serosa, 182. 

chronic, 174. 
diagnosis, 174. 
prognosis, 174. 
symptoms, 174. 
treatment, 174. 

internal, 212. 

hypertrophic, 213. 

treatment, 183. 
Meningocele, acquired, 198. 

congenital, 198. 

of cord, 224. 

pathology, 198. 

prognosis, 224. 

symptoms, 224. 

treatment, 198, 22'4. 
Metatarsalgia, 166. 
Micrencephaly, 196. 
Microcephaly, 196. 
Migraine. 121, 122. 
Milliampere, 92. 
Mind blindness, 191. 



Mitchell, J. K., Jr. 88. 
Mitchell, J. K., Sr., 334. 

S. AVeir, 58, 86, 279. 
Mixed diet, 78. 

nerves, 29. 
Monoplegia, 15, 28, 66. 
Morton's disease, 166. 

fluid, 224. 
Motor centres, 15. 

decussation, 15. 

nerves, 7. 

tract, 19. 
Multiple neuritis, 267. ^ 

aetiology, 267. 
(beri-beri), 141. 
diagnosis, 268. 
prognosis, 268. 
symptoms, 267. 
treatment, 269. 
Multipolar cells, 2. 
Muscle centres, 31. 
Muscle sense, 56. 
Muscular dystrophies, 250. 

movements, 89. 

sensibility, 68. 
Myelitis (see Inflammation of Spinal 
Cord), 262, 

causes, 263. 

diagnosis, 264. 

pathology, 263. 

prognosis, 264. 

symptomatology. 263. 

treatment, 264. 
Myelin sheath, 9. 
Myelocele syringo, 223. 
Myotoni congenita, 94. 
Myxoedema, 6L 



i Narcotics, 78. 

I Nerve, abducens, 128. 

causes of, 128-129. 

paralysis of, 128. 
afeerent, 231. 
anterior crural, 164-165. 

prognosis, 165. 

symptoms of diseases of, 165. 

treatment, 165. 
arrangement of fibre, 5. 
ascending frontal, 185. 
auditory, 131. 

disease of, 131. 

localization of, 191. 
cells, 1. 
centres, 1, 5. 
cei'vico-occipital, 153. 

cause of, 153. 

neuralgia of, 153. 

prognosis, 153. 

treatment, 153. 



IXDEX 



39^ 



Xerve, circumflex. 153. 

disease of, 153. 

distribution of, 153. 

origin of, 153. 

paralysis of. 158. 

prognosis, 154. 
cranial, disease of. 125. 
external cutaneous anterior crural, 
164. 

plantar. 166. 

popliteal. 166. 
facial, 129. 

degeneration of. 129. 
fibre. 1-4. 

functions of, 2S. 
glossopharyngeal, 1.32. 

disease of, 132. 

interosseous. 1-32. 
great sciatic, 165. 

sensory symptoms. 166. 

symptoms of disease of. 165. 
hypoglossal, nerve. 133. 

cause of, 1-34. 

centres of. 133. 

disease of. 1-34. 

symptoms. 134. 

treatment, 134. 
intercostal, neuralgia of, 118. 

prognosis of, IIS. 
internal plantar. 166. 

popliteal. 166. 
median. 157. 
musculo-spiral. 154. 

disease of, 154. 

distribution of. 154= 

prognosis, 154. 
Nerves of lower extremities, 16.3. 

trunk, 163. 
obturator, 165. 
patheticus. 128. 
peripheral. 135. 

disease of, 135. 

recurrent. 132. 
peroneal, 166. 
pneumogastric, 1-33. 

recurrent, 133. 
spinal accessory, 1.33. 

disease of. 133. 
superior gluteal. 165. 

centre, 128. 

tissue, 47. 

trifacial, 128. 
trunks, 163. 
tumours. 148. 

false neuroma. 148. 

hyperplasia. 149. 

malignant. 148. 

true neuroma. 148. 
ulnar, 156. 
vaso-constrictor, 27. 



Nervous diseases, cause of, 77. 

endarderitis obliterans, 27S. 

gummata, 273. 

gummatous meningitis, 273. 

syphilis, diseases of blood-vessels, 
272. 

temperament, 64. 
Neuralgia, 117. 

anterior crural, 119. 

cervico-occipital. 1.53. 

facial, 1.53. 

of heart tand pseudo angina, see 
Htsteria). 302. 

parasthetic. 163. 

sciatic. 118. 

visual. 129. 
Neurasthenia, 298. 

causes of. 295-296. 

definition. 295. 

diagnosis. 298. 

pathology, 298. 

primary. 298. 

prognosis. 298. 

relation of genital organs to, 296. 

secondary, 298. 

symptoms, 296. 
sensory, 297. 

va so-motor. 297. 
Neuraxon, 2. 
Neuritis, arsenical. 141. 

setiology. 139. 

atrophy in. 137. 147. 

chronic. 137. 

deformity in. 144. 

diagnosis. 141. 

diphtheria. 140, 

interstitial. 136. 

lead, 140. 

leprous, 143. 

local. 136. 

multiple. 136. 138, 139. 
j obturator, 141. 

oculomotor, 127. 
palsy, 127. 

olfactory. 125. 

parenchymatous. 136. 

pneumogastric. 133. 

prognosis. 138. 

reaction of degeneration in, 136. 

reflexes in. 138. 

special, 139. 

subacute, 137. 

symptoms. 137. 
Neurilemma. 2. 

Neuro-bilious temperament, 64. 
Neuroglia. 46. 
Neuron. 2. 74. 

Nodal change in muscle, 94. 
Nodes. Eanvier. 4. 
Nuclei of Burdach and Goll. 18. 



398 



TEEATISE ON NERVOUS DISEASES 



Nucleus ruber, 2, 18. 

emboliformis, 20. 

fastigii, 20. 

glabosus, 20. 
Nystagmus, 37, 69. 



Object blindness, 191. 
Occipital lobe, 183. 
Occupation neurosis, 313. 

causes, 313. 

definition, 313. 

muscular cases, 313. 

prognosis, 314-315. 

treatment, 315. 

vascular cases, 313-314. 
Ocular disturbances, 69. 
CEdema, 49. 
Obm, 49. 
Ohm's law, 92. 
Olivary body, 14. 
Ophthalmoplegia externa, 127. 

interna, 127. 
Opium poisoning, symptoms of acute, 
358. 

prognosis of acute, 358. 

symptoms of chronic, 358.* 

treatment of acute, 358. 
Optic atrophy in tabes, 228. 
thalamus, 18, 21, 186. 



Pachymeningitis spinal, 212. 

cerebral acute, 172. 

cerebral internal hsemorrhagica. 
175. 

externa, 171, 212. 

hypertrophic, 215. 

interna, 212. 

prognosis, 173. 

symptoms, 212. 

treatment, 173. 
Paget's disease, 333. 
Pantomime, 190. 
Paracentral lobule, 185. 
Paradoxical contraction, 59. 
Pareesthesia, 53, 65. 
Parsesthetic melalgia, 163, 
Parageusia, 73. 
Paragraphia, 193. 
Paralexia, 193. 

Paralysis agitans (see Shakinc 
Palsy), 267. 

cause, 269. 

prognosis, 271, 

symptoms, 270. 

treatment, 271. 
Paralytic stage in tabes, 229. 
Paramemia, 191, 198. 
Paraphasia, 194. 



Paraplegia, 66. 

Paresis, alcoholic, 362, ,370. 

alcoholic pseudo-, 362, 370. 

hypochondriacal type, 366. 

syphilitic pseudo-, .366. 

treatment, 370. 
Parturition centre, 26. 
Patellar reflex, 25. 
Pathological gaits, 62. 
Pathology of nervous system, 49. 

of primary ascending lateral scle- 
rosis,' 235. 

of tabes, 231. 
Paths of spinal cord, 26. 
Pegleg, 166. 

Perforating ulcer in tabes, 229. 
Perineurium, 5. 
Pfliiger's law, 24. 
Phenacetine, use of, 366. 
Physical care of nervous cases, 188. 
Physiognomy, 66, 
Pia mater, 20, 22. 
Piersol, Dr., 4. 
Piesmeter, 68. 
Plantar reflex, 25, 57. 
Poisons, 24, 50. 

Polio-encephalitis, chronic superior, 
209. 
, inferior, 209. 
diagnosis, 209. 
prognosis, 209. 
treatment, 209. 
Pons Varolii, 16, 17, 188. 
Pontine lesions, 56. 

nncleii, 17. 
Porencephaly, 197. 
Post-hypnotic suggestion, 106. 
Posterior commissure, 7. 

spinal sclerosis, 226. 
Pott's disease, 163. 
Precocious children, 78, 
Prefrontal region, 186, 
Pressure sense, 68. 
Primary optic atrophy. 228, 

lateral sclerosis, 2,35. 
diagnosis, 235. 
pathology of, 235. 
treatment, 234. 
Prognosis of cerebro-spinal disease, 
and treatment, 275. 
paralysis in, 237. 

primary lateral sclerosis, 236. 

pseudo-hyperti'ophic paralysis, 252. 
Propulsion, 63. 
Proteids, 33. 

Pseudo-bulbar palsy, 259. 
treatment, 259. 

hypertrophic paralysis, 252. 

reflex, 251. 
Psoas's abscess, 163. 



INDEX 



399 



Psychic deafness, 193. 
Psychoses, 53. 
Purkiuje cells, 20. 

Rabies ^see Hydrophobia), 346. 
Reaction of degeneration, 94. 
Reflex accommodations, 60. 

arc. 23. 

light, 60. 
Reflexes, 24, 25, 56. 126. 

abdominal, 25. 

ano-spinal, 26. 

bulbo cavernosus, 75. 

cilio-spinal, 25. 

contra-lateral, 58. 

cremasteric, 25. 

cutaneous. 73. 

deep, 74. 

elbow, 58. 

epigastric, 25. 

genito-spinal, 26. 

genito-urinary. 94. 

infra-orbital. 57. 

irritative. 121. 

palmar, 57. 

parturition, 26. 

patellar, 25. 

plants, 25. 

scapular, 25. 

sweat centres, 26. 

tendo-Achilles, 59. 

vaso-motor, 25. 

vesico-spinal, 26. 

visceral, 73. 

wrist, 59. 
Regulation of galvanic current, 98. 
Relay station, motor sensory nerves, 

33. 
Remak, fibres of, 5. 
Rest treatment, 102, 106. 
Restiform bodies. 16. 
Retropulsion, 63. ^ 
Rheostat, 98. 

Rhizomelique spondylitis, 168. 
aetiology, 168. 
girdle sensation, 170. 
pains, 168. 
pathology, 168. 
prognosis, 170. 
symptoms, 168. 
treatment, 170. 
Risus sardonicus, 348. 
Romberg. 228. 
Romberg's sign, 61, 228. 

Salaam convulsions. 312. 
Saltatory spasm, 287. 
Sanguineous temperament, 64. 
Scapular reflex, 25. 



Schiff, 26. 

Schmidt segments, 4. 
Schwann, white substance of, 4. 
Sciatic neuralgia, 119. 
neuritis, 162. 
double, 147. 
pelvic disease, 147. 
Scleroderma, 329. 
circumscribed. 329. 
diffuse, 330. 
pathology. 330. 
Sclerosis, 49. 
Scottish douche. 85. 
Secretory phenomena. 64. 
Sensation of motion, 69. 
Sense of weight, 68. 
Sensorio-motor region. 185. 
decussation, 28. 
nerve, 7. 
tracts, 19. 
Shower-baths in nervous diseases, 83. 
Sinusoidal current, 99. 
Smell, 72. 
Somnolence, 198. 

Somnolent disorders of sleep, 372-373. 
Soul blindness, 191. 
Spasm, 53, 63. 
Spastic gait, 62. 

hemiplegic gait, 62, 202, ' 
reflexes, 60. 
spinal paralysis, 236. 
diagnosis. 237. 
prognosis, 238. 
symptoms, 237. 
treatment, 238. 
Spina bifida, 224. 
diagnosis, 224. 
prognosis, 224. 
treatment, 224. 
Spinal accessory, torticollis. 1.33. 
Spinal cord, 5. 

asymmetry of, 226. 
double canal of. 226. 
meningocele, 224. 
splitting of. 226. 
hypersemia, 243. 
aetiology, 243. 
chronic, 243. 
pathology, 243. 
symptoms, 24.3. 
treatment, 243. 
membranes, inflammation of, 212. 
meningeal haemorrhage. 244. 
aetiology. 244. 
diagnosis. 244. 
prognosis, 245. 
treatment. 245. 
meningo-myelocele, 223. 
I nerve, disease of, 151. 
1 destructive symptoms of, 151. 



400 



TREATISE ON NERVOUS DISEASES 



Spinal nerve, irritative symptoms of, 
151. 
paralysis, 454. 
reflex, 23. 
Stabile current, 98. 
Station, 61. 

Steam-baths in nervous diseases, 84. 
Strabismus, 37. 
Strength of stimuli, 43. 
Stupor, 53. 

Subjective sensation, 45. 
Substantia gelatinosa centralis, 7. 

lateralis, 7. 
Sudden changes in hair, 320. 
pathology, 321. 
prognosis, 321. 
treatment, 321-322. 
Sunstroke (insolation, thermic fever, 
coup de soleil). 34. 
prognosis, 34. 
Suspension (tabes), 233. 
Sway, 228. 
Sweat centres, 26. 
Sylvius, 21, 49. 

Sympathetic system, 28. 138. 
Symptoms, of cerebral syphilis, 273. 
of primary lateral sclerosis, 234. 
of spinal paralysis, 237. 
of spinal syphilis, 274. 

diagnosis, 275. 
syringomyelia, 248-249. 
treatment, 247-248. 
Syphilis in nervous diseases, 272, 331. 
Syringomyelia, .223. 



Tabes, 232. 

causes, 231. 

diagnosis, 231. 

dorsalis, 226. 

duration, 231. 

pathology, 231. 

prognosis, 232. 

stages of, 226. 

treatment, 231-234. 
Tapotement, 87. 
Tastes, 72. 

Tea and coffee poisoning, 3.57. 
Tegmentum, 17, 188. 
Temperament, 63. 

bilious, 64. 

lymphatic, 63. 

neuro-bilious, 64. 

sanguineous, 64. 
Temperament, 76. 

in erythromelalgia, 76. 

sense, 56. 
Temporal lobe, 186. 
Tetanilla (see Tetany), 350. 
Tetanus (see Lockjaw), 350. 



! Tetany, 350. 
aetiology, 350. 
diagnosis, 852. 
symptoms, 350. 
treatment, 353. 
Thermal stimuli, 29. 
Thomsen's disease, 288. 
diagnosis, 288. 
pathology, 288. 
treatment, 288. 
Thrombosis, 89. 
Tic, convulsive, 68. 
douloureux, 53, 117. 
diagnosis, 118. 
pathology, 118. 
prognosis, 118. 
symptoms, 117. 
treatment, 118. 
Titubating gait, 63. 
Tract, ascending degeneration of, 14. 
descending, 13. 
differentiation of, 9. 
direct cerebellar, 14. 
Transmission of nerve symptoms, 32. 
Traumatic hysteria, 311. 
pathology, 311. 
prognosis, 311. 
treatment, 312. 
Treatment of nervous disorders, 77. 
of primary lateral ascending sclero- 

• sis, 236. 
of spinal paralysis, 237. 
Tremors, 68, 286. 
Trophic centres, 27. 
disturbances, 60. 
Trousseau's sign, 351. 
Tuberculosis, 49. 
Tuerck, 11. 
Turkish bath, 82. 
bathing, 81. 

Unipolar cells, 2. 
Use of electricity, 102. 

Vaso-constrictor nei'ves, 27. 
Vaso-motor nerves, 27, 36. 

centre, 27, 36. 

disturbances, 60. 
Ventricles of brain, 221. 
Verbal amnesia, 198. 
Vermiform process, 19. 
Vermis, 188. 
Vertigo, 113. 

causes, 113. 

diagnosis, 113. 

prognosis, 114. 

symptoms, 114. 

treatment, 114. 
Vesico-spinal centre, 20. 



INDEX 



401 



Visceral neuralgia, 120. 

reflex, GO, 75. 
Visual centre, 41. 
Volt, 92. 
Voluntarj- inhibition, 24. 

Waldeyer, 2. 

Wallerian method, 9. 

Water as a tonic, 84. 

Weber and Fechner's law, 43. 



Weber, law of, 43. 
Wernicke, 70. 
Wernicke's hemiopic 

action, sign, 70. 
Whistle, Galton's, 72. 
Woorara, 29. 
Wrist reflexes, 29. 



Zappert, 362. 



pupillary In- 



(1) 



THE END 



26 



DISEASES OF THE HEART 
AND ARTERIAL SYSTEM 

By ROBERT H. BABCOCK, A.M., M.D. 

Professor of Clinical Medicine and Diseases of the Chest, College of Physicians 

and Surgeons (Medical Department of the Illinois State University), 

Chicago ; Attending Physician to Cook County Hospital for 

Consumptives ; Fellow and former President of the 

American Climatological Association, etc. 

Three Colored Plates and One Hundred and Thirty-nine 
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called original work. Certainly a large amount of material, both clinical and literary, 
has been worked out and presented in a most clear, succinct, and practical manner. 
The author's style is pleasing and without ambiguity, nor is the text over-loaded with 
unnecessary technical terms. After a careful perusal of Dr. Babcock's book there are 
two features which strike the reader as characteristic and valuable. These are, on 
the one hand, the case histories, and, on the other, the unusual number and value of 
the pages devoted to the therapeutics of the subject. The narration of cases, although 
at times in much detail-, does not cause the usual weariness of flesh in the reading, 
mainly because of the interesting manner in which they are written. They are 
particularly well chosen to illustrate the manifold varieties of disease and the practical 
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"The book can be unhesitatingly recommended as a distinct acquisition to one's 
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" We commend to our readers this work of Babcock's as a very desirable work 
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A TREATISE ON 
MENTAL DISEASES 



By -HENRY J. BERKLEY, M. D. 

Clinical Professor of Psychiatry, Johns Hopkins University 
Chief Visiting Physician to the City Insane Asylum, Baltimore 



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as well as to the alienist, this work will prove very vd\w^h\&y— Journal of Nei'vous and 
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making of the book." — New Orleans Medical and Surgical yournal. 

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1 



PEACTICAL DIETETICS, 

WITM SPECIAL REFEEENGE TO DIET IX DISEASE. 
By W. GILMAN^ TIIOMPSOISr, M.D., 

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THE SURGICAL DISEASES 

OF THE GENITO-URINARY 

ORGANS. 

By E. L KEYES, A.M., M. D., LL. D., 

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St. Elizabeth Hospital ; formerly Professor of Genito-Urinary Surgery, 

Syphilology, and Dermatology at the Bellevue Hospital 

Medical College, etc. ; and 

E. L KEYES, Jr., A. B., M. D., Ph.D., 

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INTRODUCTION 

TO THE STUDY OF 

MEDICINE 

By G. H. ROGER 

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would like to know the reasons and relations of things." — Medical Times, Denver, Col. 

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medicine and its tendencies at the present ^a.y.''— Albany Medical Annals, Albany, lY. Y. 

" As a resume of recent medical advancement we may expect this volume to occupy a 
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knowledge of the causation of disease, lesions and reactions of the organism which are dis- 
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lectures and laboratory experience. Some of the principal chapters deal with the mechanical, 
physical, chemical, and animate agencies of disease, the general etiology and pathogenesis of 
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THE DISEASES OF INFANCY 
AND CHILDHOOD. 

By L. EMMET HOLT, A. M., M. D , 

Professor of Diseases of Children in the College of Physicians -and Surgeons (Columbia 

University) ; Consulting Physician to the New York Infant Asylum, 

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afford to be without it." — Boston Medical and Surgical Journal. 

"No radical departure from the previous edition has been instituted in this the 
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addition of new and thoroughly tried methods of diagnosis and treatment which have 
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have been replaced by newer and better ones. New charts and diagrams, with twenty- 
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— Yale Medical Journal. 

" Holt is recognized as one of the foremost authorities on pediatrics of America, 
and therefore of the world. He has made a very extensive first-hand study of the care 
of children and tneir diseases, and so writes from a mind replete with the clinical 
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and the text embraces 1161 octavo pages. The student or practitioner who has Holt 
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practise."— D^;/tJ^/ Medical Times. 

''The changes within the past five years have not been very extensive, yet the 
many new facts that have come out in the rapidly advancing science of pediatrics have 
here all received their share of careful and judicial treatment. 

]' The extremely practical question of infant feedino:, as is well known, has been a 
subject of special study by the author, and one in which medical advances have been 
made very largely identified with his name. It is a pleasure to find the subject han- 
dled in a text-book in a comprehensive and yet common-sense manner." — New York 
Medical News. 

D. APPLETON AND COMPANY, NEW YORK. 



F£S 24 1904 



